EVALUATION OF OPTIONS FOR 

IMPROVING AMTRAK’S PASSENGER

ACCOUNTABILITY SYSTEM

U.S. Department

of Transportation

Federal Railroad

Administration

Office of Research

and Development

Washington, DC 20590

Final Report

December 2005

This document is available to the public through the National 

Technical Information Service, Springfield, VA 22161. This 

document is also available on the FRA Web site at 

www.fra.dot.gov.

DOT/FRA/ORD-05/06
Notice

This document is disseminated under the sponsorship

of the Department of Transportation in the interest of

information exchange. The United States Government

assumes no liability for its contents or use thereof.

Notice

The United States Government does not endorse

products or manufacturers. Trade or manufacturers’

names appear herein solely because they are

considered essential to the objective of this report.
REPORT DOCUMENTATION PAGE Form Approved 

 OMB No. 0704-0188 

Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Washington Headquarters Services, Directorate for Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302, and to the Office of Management and Budget, Paperwork Reduction Project (0704-0188), Washington, DC 20503. 

1. AGENCY USE ONLY (Leave blank) 2. REPORT DATE 

December 2005 

3. REPORT TYPE AND DATES COVERED 

Final Report 

December 2005 

4. TITLE AND SUBTITLE 

Evaluation of Options for Improving Amtrak’s Passenger Accountability System 

6. AUTHOR(S) 

Ronald Mauri and Joseph Mergel 

5. FUNDING NUMBERS 

RR93/CB043 

7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 

U.S. Department of Transportation 

Research and Innovative Technology Administration 

John A. Volpe National Transportation Systems Center 

55 Broadway 

Cambridge, MA 02142-1093 

8. PERFORMING ORGANIZATION 

REPORT NUMBER 

DOT-VNTSC-FRA-05-08 

9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES) 

U.S. Department of Transportation 

Federal Railroad Administration 

Office of Research and Development 

1120 Vermont Avenue, NW 

Mail Stop 20 

Washington, DC 20590 

10. SPONSORING/MONITORING 

 AGENCY REPORT NUMBER 

DOT/FRA/ORD-05/06 

11. SUPPLEMENTARY NOTES 

12a. DISTRIBUTION/AVAILABILITY STATEMENT 

This document is available to the public through the National Technical Information Service, 

Springfield, Virginia 22161. 

12b. DISTRIBUTION CODE 

13. ABSTRACT (Maximum 200 words) 

In investigating the derailment of Amtrak's Auto Train on April 18, 2002, the National Transportation Safety Board (NTSB) 

reported that an accurate count of persons on the train at the time of the accident was not available at the accident scene. NTSB 

noted that emergency response would be improved with accurate count data at the accident scene and issued a Safety 

Recommendation to the Federal Railroad Administration (FRA) that it develop and implement an accurate passenger and crew 

accountability system. This report assesses the weaknesses in Amtrak’s passenger accounting system, the costs of improving it,

and the potential safety and business benefits of an improved system. It finds that while technically feasible, the recommendation 

is impractical given Amtrak’s business model and would not provide the desired safety benefits. It also identifies alternative

improvements to Amtrak’s passenger accounting system that can be the basis for future cost-effective Amtrak initiatives. 

15. NUMBER OF PAGES 

208 

14. SUBJECT TERMS 

Passenger Accountability, Amtrak, National Transportation Safety Board, Federal Railroad 

Administration, Safety, Emergency Response 

16. PRICE CODE 

17. SECURITY CLASSIFICATION 

 OF REPORT 

Unclassified

18. SECURITY CLASSIFICATION 

 OF THIS PAGE 

Unclassified

19. SECURITY CLASSIFICATION 

 OF ABSTRACT 

Unclassified

20. LIMITATION OF ABSTRACT 

Unlimited 

NSN 7540-01-280-5500 Standard Form 298 (Rev. 2-89) 

Prescribed by ANSI Std. 239-18 

298-102 
ii 

METRIC/ENGLISH CONVERSION FACTORS 

ENGLISH TO METRIC METRIC TO ENGLISH

LENGTH (APPROXIMATE) LENGTH (APPROXIMATE) 

1 inch (in) = 2.5 centimeters (cm) 1 millimeter (mm) = 0.04 inch (in) 

1 foot (ft) = 30 centimeters (cm) 1 centimeter (cm) = 0.4 inch (in) 

1 yard (yd) = 0.9 meter (m) 1 meter (m) = 3.3 feet (ft) 

1 mile (mi) = 1.6 kilometers (km) 1 meter (m) = 1.1 yards (yd) 

 1 kilometer (km) = 0.6 mile (mi)

AREA (APPROXIMATE) AREA (APPROXIMATE) 

1 square inch (sq in, in2) = 6.5 square centimeters 

(cm2

) 

1 square centimeter (cm2

) = 0.16 square inch (sq in, in2) 

1 square foot (sq ft, ft2) = 0.09 square meter (m2) 1 square meter (m2) = 1.2 square yards (sq yd, 

yd2

) 

1 square yard (sq yd, yd2) = 0.8 square meter (m2) 1 square kilometer (km2) = 0.4 square mile (sq mi, mi2) 

1 square mile (sq mi, mi2) = 2.6 square kilometers 

(km2

) 

10,000 square meters (m2

) = 1 hectare (ha) = 2.5 acres 

1 acre = 0.4 hectare (he) = 4,000 square meters (m2) 

MASS - WEIGHT (APPROXIMATE) MASS - WEIGHT (APPROXIMATE) 

1 ounce (oz) = 28 grams (gm) 1 gram (gm) = 0.036 ounce (oz) 

1 pound (lb) = 0.45 kilogram (kg) 1 kilogram (kg) = 2.2 pounds (lb) 

1 short ton = 2,000 pounds 

(lb) 

= 0.9 tonne (t) 1 tonne (t) =

=

1,000 kilograms (kg) 

1.1 short tons

VOLUME (APPROXIMATE) VOLUME (APPROXIMATE) 

1 teaspoon (tsp) = 5 milliliters (ml) 1 milliliter (ml) = 0.03 fluid ounce (fl oz) 

1 tablespoon (tbsp) = 15 milliliters (ml) 1 liter (l) = 2.1 pints (pt) 

1 fluid ounce (fl oz) = 30 milliliters (ml) 1 liter (l) = 1.06 quarts (qt) 

1 cup (c) = 0.24 liter (l) 1 liter (l) = 0.26 gallon (gal) 

1 pint (pt) = 0.47 liter (l) 

 1 quart (qt) = 0.96 liter (l) 

1 gallon (gal) = 3.8 liters (l) 

1 cubic foot (cu ft, ft3) = 0.03 cubic meter (m3) 1 cubic meter (m3) = 36 cubic feet (cu ft, ft3) 

1 cubic yard (cu yd, yd3) = 0.76 cubic meter (m3) 1 cubic meter (m3) = 1.3 cubic yards (cu yd, yd3)

TEMPERATURE (EXACT) TEMPERATURE (EXACT) 

[(x-32)(5/9)] °F = y °C [(9/5) y + 32] °C = x °F

QUICK INCH - CENTIMETER LENGTH CONVERSION

0 1 2 34 5

Inches

Centimeters 01 3 2 6 11 4 5 7 13 8 9 10 12

QUICK FAHRENHEIT - CELSIUS TEMPERATURE CONVERSION

 -40° -22° -4° 14° 32° 50° 68° 86° 104° 122° 140° 158° 176° 194° 212°

 

°F

 °C -40° -30° -20° -10° 0° 10° 20° 30° 40° 50° 60° 70° 80° 90° 100°

For more exact and or other conversion factors, see NIST Miscellaneous Publication 286, Units of Weights and 

Measures. Price $2.50 SD Catalog No. C13 10286 Updated 6/17/98
iii 

Table of Contents 

Section Page

Executive Summary........................................................................................................ vii 

1. Background and Purpose..............................................................................................1 

1.1 Background...........................................................................................................1 

1.2 Objective...............................................................................................................1 

2. Types of Amtrak Routes................................................................................................3 

3. Amtrak Route Characteristics......................................................................................7

3.1 Service Characteristics and Ridership ..................................................................7 

3.2 Stations..................................................................................................................7

3.2.1 Station Staffing .........................................................................................7 

3.2.2 Passenger Boardings .................................................................................8 

3.2.3 Station Intervals ........................................................................................9 

4. Rail Passenger Accountability Systems .....................................................................11

4.1 Amtrak’s Existing System ..................................................................................11 

4.1.1 Introduction.............................................................................................11 

4.1.2 Types of Train Riders and Ticketing Procedures ...................................11 

4.1.3 Boarding Procedures...............................................................................12 

4.1.4 Conductor’s Ticket Pouch.......................................................................14 

4.1.5 Amtrak’s Printed Train Manifest and Arrow CRS .................................17 

4.1.6 Conclusions on Amtrak’s Existing Passenger Accounting 

Systems ...................................................................................................21 

4.2 Past Initiatives to Improve Amtrak’s Passenger Accounting System.................22 

4.3 Amtrak’s Current Initiative to Improve Passenger Accounting .........................25 

4.4 Foreign Systems..................................................................................................27 

4.4.1 Eurostar Service......................................................................................27 

4.4.2 British Rail..............................................................................................28 

4.4.3 Japanese Intercity Passenger Trains........................................................28 

4.4.4 French Intercity Railways.......................................................................30 

5. Amtrak Accident History............................................................................................31

5.1 Accident Data for Reserved versus Unreserved Trains ......................................31 

5.2 Accident Details..................................................................................................32 
iv 

Table of Contents (continued) 

Section Page

6. Value of an Accurate System for Accounting for Persons on Board Amtrak 

 Trains ..........................................................................................................................41 

6.1 Role of Passenger Accounting in Recent Fatal Accidents..................................41 

6.2 Factors Affecting Passenger Survivability in a Train Accident..........................50 

6.3 Emergency Responders’ Perspective on the Value of an Accurate Manifest.....52 

6.4 Hypothetical Scenario in Which Survivability is Affected by Passenger 

 Accounting..........................................................................................................55 

6.5 Conclusions about the Value of an Accurate System for Accounting for 

 Persons on Board Amtrak Trains........................................................................55 

7. Alternative System Concepts for Improved Passenger Accounting: 

 Description and Evaluation.......................................................................................59

7.1 Introduction.........................................................................................................59 

7.2 Alternatives for Improved Passenger Accounting ..............................................61 

7.2.1 Base Case................................................................................................64 

7.2.2 Improved Onboard Paper-Based System................................................66 

7.2.3 Automated Onboard Ticket Collection System ......................................67 

7.2.4 Automated Onboard Ticket Collection System with Improved 

 Information Transfer...............................................................................71 

7.2.5 Electronic Tickets with Platform Readers and Car Door Readers..........75 

7.2.6 Electronic Tickets with Car Door Readers .............................................80 

7.3 Potential Benefits of Electronic Ticketing..........................................................84 

7.4 Conclusions.........................................................................................................87 

Bibliography .....................................................................................................................93 

Acronyms..........................................................................................................................95 

Appendices:

A. Amtrak Manifest Samples............................................................................................97 

B. Passenger On-Board Record Procedures from Amtrak 

 Service Standards Manual for Train Service and On-Board Service Employees......105 

C. Passenger Accountability Forms................................................................................109 

D. Summary of NTSB Accident Reports and Briefs Related to 

 Amtrak Accidents, 1993 to 2003 ...............................................................................115 

E. Emergency Preparedness Guidelines for Passenger Trains........................................159 
v 

Table of Contents (continued) 

Section Page

F. Amtrak Injury/Fatality Accidents by Type of Service ...............................................163 

G. Amtrak Route Characteristics by Route.....................................................................169 

H. Cost Estimate Assumptions for System Improvements.............................................179

I. Excerpts from Amtrak’s FY 2005-2009 Strategic Plan...............................................189 
vi 

List of Tables 

Table Page

1. Selected Characteristics: Amtrak Routes.......................................................................7 

2. Station Staffing by Type of Route .................................................................................8 

3. Passenger Boardings by Station Type by Route............................................................9 

4. Amtrak Passenger Casualties.......................................................................................33 

5. Amtrak Passenger Casualty Accidents by Type of Service (1993 to 2003)................34 

6. Amtrak Accidents Subject to NTSB Reports/Briefs....................................................38 

7. Characteristics of the Alternative Passenger Accountability Systems ........................62 

8. Automated Onboard Ticket Collection System ...........................................................69 

9. Automated Onboard Ticket Collection System with Improved Information 

Transfer........................................................................................................................73 

10. Electronic Tickets with Platform Gate Readers and Car Door Readers ......................78 

11. Electronic Tickets with Car Door Readers ..................................................................82 

12. Alternative Systems’ Cost Summary...........................................................................89 
vii 

Executive Summary 

Background 

In investigating the derailment of Amtrak’s Auto Train on April 18, 2002, near Crescent City, 

Florida, the National Transportation Safety Board (NTSB) observed that an accurate count of 

persons on the train at the time of the accident was not available at the accident scene. It took 

NTSB almost 5 months to develop such a count. NTSB noted that emergency response may be 

improved with accurate passenger- and crew-count data at the accident scene and thus on August 

15, 2003, issued the following Safety Recommendation, R-03-12, to the Federal Railroad 

Administration (FRA): 

In cooperation with the Transportation Security Administration, develop and 

implement an accurate passenger and crew accountability system for all longdistance, overnight, and reserved passenger trains that will immediately provide 

an accurate count and identity of the people on board the train in case of an 

emergency at any time during the trip. 

NTSB also issued similar, concurrent recommendations to the Transportation Security 

Administration (TSA) (R-03-13), and to Amtrak (R-03-10). 

FRA must assess the feasibility of implementing this recommendation, and develop a response to 

the NTSB. FRA has requested that the John A. Volpe National Transportation Systems Center 

(Volpe Center) undertake an effort to define options for such an accountability system and assess 

the feasibility of implementing them. 

Objectives 

This study has two objectives: (1) to define one or more options for a real time manifest1

 system 

for passengers and crew aboard Amtrak long-distance, overnight, and reserved trains; and (2) to 

assess the feasibility of developing and implementing such system(s). 

The improved system should be capable of providing an accurate listing of all persons on board 

at all times, including limited personal information to be used as part of an emergency response 

(i.e., name, and perhaps also age or age category, gender, and contact person/number). 

 

1

 In this report a passenger manifest is a list of the number and names of the passengers on board a train and could 

include other persons (crew). Under current practices, Amtrak’s “manifest” provides the names of first class and 

sleeper passengers holding reservations. However, it only has a count (without names) of coach reservations and is 

not checked against the number and names of passengers actually on board. Thus it is not a comprehensive 

passenger accounting system (manifest) as envisioned by NTSB. 
viii 

The feasibility assessment includes information on the required institutional changes, constraints, 

implementation costs, and the expected benefits in an emergency situation, including the 

system’s expected reliability and effectiveness. 

The system options considered do not include security functions such as options for linkages to 

other security databases for passenger screening, which may be the subject of a follow-on study. 

The following tasks were performed to meet the study objectives: 

1. Describe the existing Amtrak operations and passenger processing systems. 

2. Identify Amtrak’s past or planned initiatives to create or improve passenger processing 

procedures and systems, especially regarding manifests. 

3. Describe passenger reservation, ticketing, and control processes for a small sample of 

foreign passenger rail systems. 

4. Describe the role of passenger count and identification information in a rail accident and 

emergency response environment, and the expected benefits of the improved system. 

5. Describe options for an improved passenger accountability system and estimate their 

development, capital, and operating costs, and assess the feasibility of implementing an 

improved system. 

Conclusions in Brief 

• Rail passenger accidents in which passenger accountability could be an issue are rare 

events. 

• Amtrak’s current passenger accountability system does not and cannot meet the NTSB’s 

requirement for accurately knowing the number and identity of passengers on reserved 

trains at all times. 

• Amtrak’s business model includes open access to its trains. To meet NTSB 

requirements, Amtrak would need to make a fundamental change from an open to a 

controlled access business model. The changes include the following: 

o Elimination of onboard sales and replacement by one or more of the following: 

 Installation of ticket machines at unstaffed stations 

 Establishment of non-Amtrak sales outlets 

 Elimination of service at unstaffed stations (almost 10 percent of 

passengers currently board at unstaffed stations) 
ix 

o Validation/verification of all tickets before or during passenger boarding 

o Validation/verification of all tickets when passengers depart the train 

o Transfer of accurate manifest information from the train to a central database 

before departing each station 

• While the technology exists to implement a new business model meeting NTSB 

requirements, it may prove too costly and be viewed as inconsistent with the traditional 

business model and practices for intercity rail passenger service. 

• Potential benefits for passenger accounting system improvements include possible cost 

savings in the automation of the paper-based revenue accounting process, a change in 

emphasis in the role of the conductor from revenue collection to customer service and 

safety, improved ridership data, and more timely resolution of passenger train 

emergencies. 

• Although having an accurate passenger manifest can be useful, the development and 

implementation costs associated with such a system would likely be substantial and there 

is no significant safety benefit in having an accurate passenger manifest immediately 

available at the accident scene.

Detailed Findings and Supporting Information 

Amtrak’s passenger accounting system involves a complex set of subsystems and procedures that 

reflect its operating environment and business model. The following provides a summary of its 

main features and their impact on accuracy, an assessment of the value (safety benefits) of 

accurate passenger accounting, and a discussion of potential improvements based on the 

perspective of past initiatives, experiences in other passenger transport environments, and 

available technologies. 

Amtrak’s Existing Passenger Accountability Systems 

• Amtrak’s existing passenger accountability system is based on two components: 

o A printed manifest based on its Arrow computerized reservation system 

o The conductor’s ticket pouch 

• Amtrak’s passenger accountability system has significant shortcomings in both its design 

and actual use. 

Amtrak’s Reservation System-Based Printed Train Manifest 

• The conductor’s printed manifest does not provide a reliable basis for knowing the 

number of persons on board because it will generally include persons not on board and 

exclude other persons who are on board. It should not be used to provide passenger 

count information after an accident.
x 

• The reservation-based manifest information changes in real time while the train travels 

from origin to destination because additional tickets are purchased at downstream stations 

and on board trains. 

• Serious deficiencies exist in the procedures for transmitting information needed to update 

the reservation system and manifest for transactions occurring postdeparture. 

• An updated manifest suffers from the same weaknesses that make the original departure 

manifest unreliable.

The conductor’s manifest is printed about 30 minutes before a train’s departure. The current 

manifest provides an estimate of passenger loads and other information of value to the train 

crew, but not a full list with passenger names. Thus, no way exists of comparing whom actually 

got on the train with the information provided on the typical manifest. 

The onboard manifest is inaccurate to the extent that it includes some persons not on the train 

and excludes some persons who are on board. It may incorrectly include persons not on the 

train, mainly no-shows2

 and persons departing the train before the ticket destination. If a ticket is 

issued, Amtrak’s Arrow reservation system assumes it is used and that the passenger remains on 

the train until his or her scheduled destinations, even though it is known and expected that some 

passengers leave the train both before and after their scheduled destination. Because updates are 

often not sufficiently frequent and complete, generally the printed manifest excludes both 

passengers who board and purchase tickets on the train3

 and other non-revenue riders. 

The update process for Arrow and the printed manifest involves dropping off at staffed stations 

the records of persons boarding without tickets, and having this information entered later into 

Arrow. The update process does not include information about persons boarding at the current 

station stop, so the Arrow system is always at least one station behind. Since no-shows are not 

identified, no correction can occur for them, and the update process is not consistently executed 

since exceptions to proper recordkeeping and the drop-off process occur. 

Conductor’s Ticket Pouch 

• The conductor’s ticket pouch, if managed properly, is a more accurate source of the 

number of passengers on board at a given time than the Amtrak manifest. 

• A system based on the conductor’s recordkeeping will not be perfectly reliable in 

accounting for all passengers on board at all times. For example, records for infants and 

other non-ticket riders can be incomplete. 

 

2

 People who have purchased and picked up a ticket but do not actually board the train. 

3

 Except at a few major stations, it is possible to get on a reserved train without a ticket and without a reservation. 

Most staffed and unstaffed stations have open platform access. 
xi 

• Deficiencies in ticket pouch recordkeeping are most likely to result in ridership 

undercounts. 

• The pouch itself can easily be misplaced or destroyed in the event of an accident, and its 

information lost.

Even if Amtrak policies are followed, the ticket pouch is not a perfect passenger accounting 

system since: (1) there is a time lag to “sweep” the train and gather the records during which the 

pouch does not contain complete records of persons on board; (2) the conductor could miss 

someone when collecting tickets; (3) a passenger could leave the train before his or her 

scheduled stop without notifying the conductor either because of a personal emergency or last 

minute change in travel plans; and (4) the pouch could be destroyed or otherwise become 

unavailable in an accident. 

In actual practice, the ticket pouch records are not likely to be a very accurate basis for passenger 

accounting due to the failure to consistently record the presence of persons without prepurchased tickets on Form 3085, which is designed for this purpose. Exceptions to the use of 

Form 3085 are permitted on some reserved trains in the Northeast Corridor (NEC). Furthermore, 

given their limited perceived value and importance relative to other conductor records and 

responsibilities, lapses in other situations seem likely. To the extent this occurs, ridership counts 

based on the ticket pouch records will understate the number of persons on board. 

Regarding passenger identification, since the cash fare receipts lack passenger name information 

for multi-person groups traveling together, unless the conductor also fills out a Form 3085 for 

each individual (and, as noted, this process is not uniformly followed), incomplete records of 

individual names will exist. The same is true of the “Record of Tickets Honored but not Lifted” 

as it is applied to revenue pass holders (i.e., any failure to record information appropriately on 

Form 3085 results in missing passenger names). 

No designated or especially designed safe place exists on board for the ticket pouch. Given the 

possibility that the pouch could be destroyed or become lost in the aftermath of serious accidents 

(and it is mainly the serious accidents for which accurate passenger accounting is needed), the 

ticket pouch is not a reliable source by itself. Since no reliable and timely means of transmitting 

all of the information in the pouch to a safe repository off the train exists, the Arrow 

computerized reservation system does not provide a reliable backup capability for the ticket 

pouch information regarding the number of actual boardings by station or a name list of 

passengers on board at any given time. 

It is also notable that there do not appear to be any standard procedures in place for ticket pouch 

management, such as, sorting all tickets and forms by origin/destination or summarizing ons and 

offs after each station stop. This means that while the pouch may contain most of the 

information needed to determine the number of passengers on board, (1) the work involved in 

sorting through the individual pieces of paper after an accident precludes determining an 

accurate count of passengers on board in a timely manner; (2) it would be a daunting task for 

someone unfamiliar with the various forms and their uses to perform in the event that the 

conductor was unavailable (e.g., if the conductor were injured in a serious accident). 
xii 

Amtrak Routes and Services 

• Over three fourths of Amtrak routes involve reserved/sleeper trains, and slightly less than 

half of Amtrak passengers ride reserved/sleeper trains.4

The envisioned manifest system would apply to the routes having sleeper service and all reserved 

trains. It would not apply to unreserved trains. The manifest system would thus cover about 51 

percent of Amtrak’s passengers, 91 percent of its routes, and 51 percent of trains operated. 

• Passengers boarding at unstaffed stations are not required to pick up tickets in advance. 

• About 60 percent of the 495 unique stations served by reserved trains are unstaffed. 

• Almost 10 percent of passengers on reserved trains board at unstaffed stations. 

Amtrak provides service at 495 unique5 stations on its routes served by sleeper, reserved, and 

partially reserved trains. Of these stations, 206 (42 percent) are staffed, and 289 (58 percent) are 

unstaffed. 

Passenger boardings at unstaffed stations have potential negative implications for the passenger 

accountability system since passengers boarding at those stations cannot pick up their ticket at 

the station before boarding. Amtrak does offer the provision of sending tickets to customers via 

FEDEX, but it is believed this service is not used very often. 

For Amtrak’s 16 routes having sleeper service, 91 percent of passengers board at staffed stations. 

For Amtrak’s 18 routes having reserved trains, 92 percent of passengers board at staffed stations. 

• Spacing between staffed stations is a critical component determining the accuracy of 

passenger manifests under the current passenger accountability system. 

• Large numbers of unstaffed stations between staffed stations implies large gaps between 

manifest updates under the current system.

The spacing between staffed stations is a critical component of Amtrak’s current passenger 

accountability system. Large gaps on a route between staffed stations detract from the 

usefulness of such a system because as the time between updates increases, the value of the 

updates in terms of their currency decreases (i.e., the updated information becomes obsolete). 

Many cases of long spacings between staffed stations in the Amtrak system exist. The average 

distance between staffed stations for sleeper routes varies from about 24 miles on the Federal to 

 

4

 Data on reserved trains reflect Amtrak’s schedule of 2004. Amtrak continues to make changes in its policies 

regarding the need for reservations but the basic points in this section are still valid. 

5

 Many stations are served by more than one route. 
xiii 

about 345 miles on the Sunset Limited. The maximum station spacing between staffed stations 

for reserved routes varies from 69 miles on the Acela Express to 283 miles on the Kansas CitySt. Louis trains. 

Amtrak Initiatives to Improve Passenger Accounting 

Amtrak’s past approach to improving the passenger accountability system appears to have been 

an attempt to automate the ticket collection process. Due to technology limitations and cost or 

other practical considerations, these automation initiatives were never implemented. 

Amtrak currently has an initiative that will improve its passenger accounting capabilities to a 

certain extent if developed and implemented as planned. Significant business practice, cost, and 

technology challenges will need to be overcome, and uncertainty exists regarding details that 

affect the timeliness and accuracy of its passenger accounting capability. The current initiative 

seems to be aimed at automating Amtrak’s existing ticket lift system and communication of 

updates to Arrow. Its other inherent flaws will remain as imperfections even if a more 

automated system is implemented and used consistently. A more automated system will likely 

have the same basic deficiencies as the existing system, namely: (1) not being able to determine 

exactly who has boarded until after a sweep is completed after each stop; (2) uncertainty 

regarding whether anyone is missed in the train sweep; and (3) uncertainty regarding whether 

anyone has departed before his or her ticketed destination. 

Passenger Accounting on Foreign Passenger Rail Systems 

• Two examples of alternative closed models for improved passenger accountability were 

identified (though most foreign systems are open). 

• The closed approach, in place to varying degrees on Japan railways and Eurostar trains, 

requires all passengers to possess a ticket before entering a station’s boarding platform 

and requires a second use of the ticket to exit the system.

Generally, even among the relatively sophisticated foreign passenger rail systems examined, 

most seem incapable of providing a very accurate accounting of passengers on board. Foreign 

systems are focused more on accurate fare collection. The Japanese have the only system that 

requires electronic verification at both boarding and departing stations, though Volpe Center 

staff did not ascertain whether this information is captured by a database system. The more 

common foreign business models have features that are inconsistent with accurate passenger 

accounting practices, namely open access to and egress from trains, trains with at least some 

unreserved cars, and onboard ticket inspection done using train sweeps by conductors. It is 

likely these practices exist for cost and passenger convenience reasons.

Amtrak Accident History 

• Passenger accountability is not an issue in most Amtrak accidents because few result in 

casualties to train occupants. 
xiv 

• Only 92 of 881 (10.4 percent) of reportable accidents involving Amtrak passenger trains 

resulted in passenger casualties (injuries or fatalities) over the period 1993 to 2003, and 

only 5 (0.6 percent) resulted in at least one passenger fatality. 

• Only 32.2 percent of reported injuries to Amtrak passengers resulted from a reportable 

accident.

Although Amtrak averages about 80 accidents per year, only about a third involve passenger 

casualties, and very few (5 over an 11-year period) involved fatalities. 

The proposed manifest system would apply to sleeper trains and reserved trains not having 

sleeper service. These two types of trains combined accounted for 89.2 percent of accidents, 100 

percent of passenger fatalities, and 94.9 percent of passenger injuries. 

Value of an Accurate Passenger Accountability System 

• In the five Amtrak accidents resulting in passenger fatalities between 1993 and 2003, a 

perfectly accurate passenger manifest would not have contributed to a passenger’s life 

being saved. 

• From the perspective of first responders, the principal value of the manifest is in allowing 

them to determine that all persons have been accounted for, and that no one has been left 

behind. 

• Determining passenger names, as well as the number of passengers is an important part 

of the responders’ passenger accountability procedures. 

• In reporting an accident to an emergency response organization, providing an 

approximate number of passengers is useful in planning their response and marshalling 

the appropriate resources, but an exact count is not essential for this purpose.

In one example of its criticism of Amtrak’s passenger accountability system, NTSB has noted 

that: 

The survival of passengers and crewmembers might well depend on emergency 

responders, who in turn depend on a complete and accurate accounting of all people on 

the train to ensure that they locate, evacuate, and treat (if necessary) all those on board. If 

the passenger list does not include every passenger on the train, emergency responders 

may leave passengers behind. If the passenger list includes people not on the train, 

emergency responders may be needlessly exposed to prolonged risks as they search for 

nonexistent passengers.6

 

6

 Derailment of Amtrak Auto Train on the CST Railroad Near Crescent City, Florida, April 18, 2002, NTSB Report 

Number RAR-03-02, adopted on 8/5/2003. 
xv 

In none of the accidents that were the subject of an NTSB report, however, has the NTSB 

explicitly cited an instance where a surviving passenger had unknowingly been left behind nor an 

instance where emergency responders had spent time searching for nonexistent passengers. 

Given the sparse data available it is difficult to draw sweeping general conclusions. Based on 

the cases available (including the two involving commuter rail fatalities), however, it seems that 

the availability of a perfectly accurate passenger manifest would not have resulted in a 

passenger’s life being saved or the degree of injury reduced. No examples have been found in 

which promptly accounting for passengers and crew has affected survivability or severity of 

injury. 

Moreover, an accurate manifest is only one part of the solution to the passenger accountability 

problem. Matching known passengers to a list either by means of a simple head count, or taking 

attendance (a head count with associated names), as soon as possible after the accident is the 

other necessary part of the solution. In the Amtrak accident at Syracuse, New York, it took 

about 1 hour for first responders to count 100 passengers. In the Amtrak accident at Nodaway, 

Iowa, it took first responders between 3 and 4 hours to count 241 passengers. Of the accidents 

involving Amtrak trains that occurred between 1993 and 2003 and documented by NTSB, the 

number of Amtrak passengers has varied from 83 (Intercession City, Florida) to 413 (Crescent 

City, Florida). 

When serious Amtrak accidents occur, having a count of the number of persons on board has 

three main uses. 

• If an estimate is provided as part of the accident reporting process, first responders will 

be able to better gauge the need for resources. 

• As the search and rescue process proceeds, an accurate list to compare with persons 

evacuated can be used to determine whether persons may still be missing or that all 

persons are accounted for. 

• A list containing names and other personal information will also be of subsequent use to 

Amtrak for purposes such as notifying next of kin, and in dealing with legal liability 

matters. 

The NTSB recommendation that an accurate accounting system be developed and implemented 

implicitly assumes it would have a meaningful safety benefit. It is thus necessary to assess the 

value of such a system in terms that can be compared to the costs of implementation. Each of the 

identified uses is examined below to determine its effect on safety and indicate a measure of the 

likely impacts. 

Gauging Resources Required for an Accident Response

To gauge the amount of resources to dispatch to a rail accident, responders need information 

about the type and size of the accident and the number of casualties requiring emergency medical 
xvi 

care and transportation. Amtrak crews are trained to quickly assess the situation and include this 

information in reporting the accident. Exact counts are not essential for this purpose. 

Indicating the Possibility of Missing Persons

Emergency response teams are trained to perform systematic searches of accident and disaster 

sites to locate all victims. Part of this standard practice is to count rescued persons and collect 

personal information about these individuals. Comparing this on-site accident response 

information to records of persons on board could aid in the accounting of persons. This process 

takes time, however, and is not the first priority of emergency responders. 

Emergency responders will normally perform careful searches irrespective of any indication of 

missing persons. Inaccurate records of persons on board might cause some continuation of 

search and rescue operations that might otherwise have ceased, but only if the error was to list 

more persons than were actually on board. It is more likely that imperfections in Amtrak’s 

passenger accounting system would result in undercounts rather than overcounts of persons on 

board and thus would not cause unnecessary searches. The added costs of extending the search 

period could be extra pay for those searching, but this might be performed within regularly 

scheduled duty time. Given the potential for undercounting, emergency responders will likely 

continue the search for passengers even after all those listed on the manifest are accounted for. 

Providing Information for Post-Accident Notification and Records

As a common carrier, Amtrak has post-accident responsibilities that require information 

concerning persons on board. Pre-accident data will always be compared, verified, and 

supplemented by information collected during the emergency response. Accurate pre-accident 

information would facilitate this process, but has no significant safety benefit or notable cost 

saving other than potentially reducing fraudulent liability claims. 

Potential Costs and Benefits of an Improved Passenger Accountability System 

• Amtrak’s passenger accountability system can be improved but will require changes to its 

operating practices and increases in capital and operating costs.

• Detailed analysis of the costs of Amtrak’s existing and improved systems for ticket 

reservations, sales, collection, and revenue accounting would be required to decide what 

end-state system Amtrak should select and integrate into the long run planning of all its 

system modernization acquisitions and improvements.

• Estimated capital costs for new equipment considered in this study range from about $17 

million to over $200 million, and a system that meets NTSB requirements would cost at 

least $40 million. Additional one-time development costs would exist for changes to 

computer systems that would likely be substantial.
xvii 

• Incremental operating costs for materials and maintenance of the new systems would 

range from $2 million to $21 million annually, and meeting NTSB requirements would 

cost at least $7 million per year. Staffing changes at stations and on board trains would 

result in additional operating costs.

• Non-safety business benefits may exist to improving Amtrak’s passenger processing 

system; these should be considered in decisions regarding future system improvements.

1

1. Background and Purpose 

1.1 Background 

In investigating the derailment of Amtrak’s Auto Train on April 18, 2002, the National 

Transportation Safety Board (NTSB) observed that an accurate count of persons on the train at 

the time of the accident was not available at the accident scene; this took NTSB almost 5 months 

to develop. NTSB noted that emergency response would be improved with accurate passengerand crew-count data at the accident scene and thus on August 15, 2003, issued the following 

Safety Recommendation, R-03-12, to the Federal Railroad Administration (FRA): 

In cooperation with the Transportation Security Administration, develop and 

implement an accurate passenger and crew accountability system for all longdistance, overnight, and reserved passenger trains that will immediately provide 

an accurate count and identity of the people on board the train in case of an 

emergency at any time during the trip. 

FRA must assess the feasibility of implementing this recommendation and, consistent with its 

authority and Amtrak’s capability to implement the recommendation, develop a response to the 

NTSB. FRA requested that the John A. Volpe National Transportation Systems Center (Volpe 

Center) undertake an effort to define options for such an accountability system and assess the 

feasibility of implementing them. 

1.2 Objective 

This study has two objectives: (1) to define one or more options for a real time manifest7

system for passengers and crew aboard Amtrak long-distance, overnight, and reserved trains, and 

(2) to assess the feasibility of developing and implementing such a system. 

The improved manifest system would provide an accurate listing of all persons on board, 

including limited personal information to be used as part of an emergency response (i.e., name, 

and perhaps age or age category, gender, and contact person/number). 

The feasibility assessment will include information on the required institutional changes, 

constraints, implementation costs, and the expected benefits in an emergency situation, including 

the system’s expected reliability and effectiveness. 

 

7

 In this report, a passenger manifest is a list of the number and names of the passengers actually on board a train 

and could include other persons (crew). Under current practices, Amtrak’s printed “manifest” provides the names of 

first class and sleeper passengers holding reservations. However, it only has a count (without names) of coach 

reservations and is not checked against the number and names of passengers actually on board. Thus, it is not a 

comprehensive passenger accounting system (manifest) as envisioned by NTSB. 
2

The system will not include security functions. This study will not consider options for linkages 

to other security databases for passenger screening, but these may be the subject of a follow-on 

study. 

The following tasks were performed to meet the study objectives: 

1. Describe the existing Amtrak operations and passenger processing systems. 

2. Identify Amtrak’s past or planned initiatives to create or improve passenger processing 

procedures and systems, especially regarding manifests. The efforts identified will be 

described, including the technical nature of the system and what is known about its 

implementation and status. 

3. Describe passenger reservation, ticketing, and control processes for a small sample of foreign 

passenger rail systems. 

4. Describe the role of passenger count and identification information in a rail accident and 

emergency response environment, and the expected benefits of the improved system. A key 

issue in this task is to determine how an accurate manifest would make the emergency 

responders’ efforts more successful and the likelihood that it would be effective in typical 

accident situations. 

5. Describe options for an improved passenger accountability system; estimate their 

development, capital, and operating costs; and assess the feasibility of implementing an 

improved system. 
3

2. Types of Amtrak Routes 

In its report documenting the investigation of the Auto Train derailment,8

 the NTSB noted that 

Amtrak uses the same paper record system that performed so poorly on the Auto Train for all its 

long-distance, overnight, and reserved trains. NTSB noted that Amtrak operates the following 

trains that fall into one or more of these categories: 

Sunset Limited Cardinal 

Southwest Chief Auto Train

California Zephyr City of New Orleans 

Empire Builder Silver Palm 

Coast Starlight Silver Star 

Crescent Silver Meteor 

Texas Eagle Acela Express 

Capitol Limited Metroliner

Three Rivers Empire Service 

Lake Shore Limited 

This list appears to have been taken directly from Amtrak’s Service Standards Manual for 

Management Employees9

 then in effect. Unfortunately, the manual does not define longdistance, overnight, and reserved trains other than giving examples of trains that would fall 

within those categories. The NTSB list from Amtrak’s manual includes all sleeper trains, three 

reserved non-sleeper services, and one service (Empire Service) that does not require 

reservations of all passengers. Many trains not on this list exist that also require reservations, 

and it is assumed that they fall within the intent of the NTSB recommendation. 

In considering the question of where a manifest system would be applicable, an examination of 

the 2003 Amtrak timetable indicates that the long-distance distinction has little relevance, and no 

purpose would be served by treating it as a separate category in this report. All trains with 

sleeper service are reserved, and most of the corridor trains are reserved either completely or on 

a portion of their route. A few cases of overnight non-sleeper trains in the reserved service list 

exist. The current classification (based on the 2003 timetable) is indicated below and is used in 

the reminder of this report. 

 

8

 Derailment of Amtrak Auto Train on the CSXT Railroad Near Crescent City, Florida, April 18, 2002, NTSB 

Report Number RAR-03-02, adopted on 8/5/2003, pp. 57, 58. 

9

 Service Standards Reference Manual for Management Employees, Chapter 16 “Train 

Service Crew Functions and Accountabilities,” Part D, “Passenger On-Board Record Procedures,” reissued 

November 2002. 
4

Sleeper 

Federal (Twilight Shoreliner)10

Silver Star 

Three Rivers 

Cardinal 

Silver Meteor 

Empire Builder 

Capitol Limited 

California Zephyr 

Southwest Chief 

City of New Orleans 

Texas Eagle 

Sunset Limited 

Coast Starlight 

Lake Shore Limited 

Crescent 

Auto Train

Reserved 

Metroliner/Acela Express 

Vermonter 

Downeaster 

Chicago-St. Louis 

Chicago-Pontiac 

Illini 

Illinois Zephyr 

Heartland Flyer 

Cascades 

San Joaquins 

Adirondack 

International 

Palmetto (Silver Palm) 

Hoosier State (Kentucky Cardinal) 

Kansas City-St. Louis 

Pere Marquette 

Carolinian 

Piedmont 

 

10 In 2004, the Federal was replaced by an all reserved Regional without sleeper service. 
5

Partially Reserved11

Ethan Allen Express 

NE Direct/Acela Regional 

Maple Leaf 

Empire Service 

Unreserved 

Clocker Service 

Keystone 

Hiawathas 

Pacific Surfliner 

Capitols 

Pennsylvanian 

 

11 The Ethan Allen Express is reserved north of Albany. The Maple Leaf is reserved west of Albany. The Empire 

Service is reserved west of Albany. NE Direct/Acela Regional operates a mix of reserved/unreserved trains. In 

2003 18 percent of the Regionals were reserved. 

7

3. Amtrak Route Characteristics 

Amtrak’s passenger accounting systems, including their weaknesses and potential improvements, 

are best discussed in the context of the route characteristics described in the following 

subsections. 

3.1 Service Characteristics and Ridership 

Some characteristics of Amtrak services are listed in Table 1. An improved passenger 

accounting system would apply to the routes having sleeper service and all-reserved trains. It 

would not apply to unreserved trains. Most of the ridership and trains in the mixed category are 

unreserved Empire and Northeast Corridor (NEC) trains. Thus the passenger accounting system 

would cover about 45 percent of Amtrak’s passengers, 77 percent of its routes, and 46 percent of 

the trains operated. 

Characteristics of Amtrak services for each route are listed in the tables of Appendix G. 

Table 1. Selected Characteristics: Amtrak Routes 

Route Type Ridership Percent

Number of 

Routes in 

Category Percent 

Trains/Week 

(Both Ways) Percent

Sleeper 3,928,477 16.7% 16 36.4% 208 11.4%

Reserved Non Sleeper 6,723,144 28.7% 18 40.9% 628 34.5%

Unreserved 5,795,352 24.7% 6 13.6% 570 31.3%

Mixed: 

Reserved/Unreserved 7,009,731 29.9% 4 9.1% 415 22.8%

Total 23,456,704 100.0% 44 100.0% 1,821 100.0%

All data are for 2003 

3.2 Stations 

3.2.1 Station Staffing 

Passenger boardings at unstaffed stations have potential implications for Amtrak’s passenger 

accounting systems because passengers are not required to pick up their ticket before boarding at 

these unstaffed stations. Amtrak does offer the provision of sending tickets to customers via 

FEDEX, but this service is not used very often.12 Unticketed passengers detract from the 

usefulness of the printed manifest the conductors receive before departure and at crew change 

points. 

 

12 Telephone conversation with Rich Reccardi, Amtrak Human Resources Officer, March 25, 2004. 
8

Amtrak provides service at 495 unique13 stations on its routes served by sleeper, reserved, and 

partially reserved trains. Table 2 illustrates the mix of staffed and unstaffed stations by route 

type. Of stations serving reserved routes, 206 (42 percent) are staffed, and 289 (58 percent) are 

unstaffed. Of the 340 unique stations served by Amtrak’s 16 routes having sleeper service, 159 

(47 percent) are staffed and 181 (53 percent) are unstaffed. Of the 215 unique stations served by 

Amtrak’s 18 routes having reserved trains, 101 (47 percent) are staffed, and 114 (53 percent) are 

unstaffed. Of the 60 unique stations served by Amtrak’s 4 routes having trains reserved over a 

portion of the route or a mix of reserved and unreserved trains, 44 (73 percent) are staffed and 16 

(27 percent) are unstaffed. It is apparent from these data that unstaffed stations are a major 

element in Amtrak’s operations and business model, and permitting passengers to board without 

tickets from such stations is a long-standing policy and practice. The tables in Appendix G show 

the breakdown of staffed and unstaffed stations within each type of service. 

Table 2. Station Staffing by Type of Route 

 Unique Stations Served 

Route Type Total Staffed Percent Unstaffed Percent

Sleeper 340 159 47% 181 53%

Reserved 215 101 47% 114 53%

Partially Reserved 60 44 73% 16 27%

Total Manifest 

Trains 495 206 42% 289 58%

3.2.2 Passenger Boardings 

An examination of passenger boardings at all stations served by Amtrak’s reserved trains 

indicates that 94 percent of passengers board at staffed stations (see Table 3). For Amtrak’s 16 

routes having sleeper service, 91 percent of passengers boarded at staffed stations. For Amtrak’s 

18 routes having reserved trains, 92 percent of passengers boarded at staffed stations, and for 

Amtrak’s 4 routes having trains reserved over a portion of the route or a mix of reserved and 

unreserved trains, 98 percent of passengers boarded at staffed stations. The tables in Appendix 

G show the breakdown of passenger boardings for staffed and unstaffed stations within each type 

of service. 

 

13 Many stations are served by more than one route. 
9

Table 3. Passenger Boardings by Station Type by Route 

Passenger Boardings 

Type Total Staffed Percent Unstaffed Percent

Sleeper 3,928,477 3,561,965 91% 366,512 9%

Reserved 6,723,144 6,188,464 92% 534,680 8%

Partially Reserved 7,009,731 6,882,310 98% 127,421 2%

Total Manifest Trains 17,661,352 16,632,739 94% 1,028,613 6%

3.2.3 Station Intervals 

The spacing between staffed stations is a critical component of Amtrak’s current passenger 

accountability system. Ideally, under the current system, conductors drop off hand-generated 

updates to the manifest at each staffed station so that the data can be entered into the 

computerized reservation system. The conductors then pick up an updated version of the train 

manifest at the next staffed station downstream. Large gaps on a route between staffed stations 

detract from the usefulness of such a system in two ways. First, as the time between updates 

increases, the value of the updates in terms of their currency decreases (i.e., the updated 

information becomes obsolete). Secondly, in terms of accident theory, as the distance between 

stations is increasing, all other things being equal, accident exposure (the likelihood that an 

accident will happen) is also increasing. 

The tables in Appendix G show station spacing by route. When all stations on a sleeper route are 

considered, the average distance between stations varies from about 24 miles on the Federal14 to 

about 73 miles on the Southwest Chief. (The Auto Train is a special case serving a single origindestination pair 855 miles apart.) The maximum station spacing varies from 69 miles on the 

Federal to 263 miles on the California Zephyr. When only staffed stations on a route are 

considered, the average distance between stations generally increases. It varies from about 24 

miles on the Federal (all stations served are staffed stations) to about 345 miles on the Sunset 

Limited. The maximum station spacing varies from 69 miles on the Federal to 622 miles on the 

Sunset Limited. 

Distances between stations for reserved or partially reserved non-sleeper routes are shorter but 

still substantial. For example, the maximum spacing between staffed stations varies from 69 

miles on the Acela Express to 283 miles on the Kansas City-St. Louis trains. 

Thus, there are many cases of long spacings between staffed stations in the Amtrak system. 

Because staffed stations are used in updating Amtrak’s passenger counts, these spacings are a 

factor that must be considered in assessing the design and reliability of their passenger 

accounting systems. 

 

14 In 2004, the Federal was replaced by an all reserved Regional without sleeper service. 

11

4. Rail Passenger Accountability Systems 

4.1 Amtrak’s Existing System 

Amtrak’s existing passenger accounting process involves its computerized reservation system 

(Arrow) and onboard records and procedures. 

4.1.1 Introduction 

Amtrak’s existing approach to accountability of passengers on board reserved trains is based on 

two systems, a manifest (as that term is used by Amtrak) and the conductor’s ticket pouch. On 

unreserved trains, which in most cases can be viewed as up-scale commuter railroads, although 

passenger tickets or other authorizing documents are collected or checked, no attempt is made to 

keep a count of the number of passengers on board at any time. 

Currently, Amtrak manifests are produced by Amtrak’s computerized reservation system (CRS), 

known as Arrow, and are based on its reservations and ticket sales. As the name implies, the 

conductor’s ticket pouch is based on tickets. It should be noted that, because of no-shows, in any 

common carrier passenger service the advance reservations do not necessarily equal tickets 

purchased, which, in turn, do not necessarily equal tickets used (i.e., passenger boardings). This 

basic fact is one key reason for the inconsistencies noted by NTSB in its criticism of Amtrak’s 

past inability to provide an accurate accounting of passengers following a train accident, but 

there are also other Amtrak policies and business practices that inhibit timely and accurate 

passenger accounting. 

An ideal passenger accountability system would provide an accurate count of passengers on 

board the train at any given time, their location on the train (per comment of emergency 

responders), and basic information on each passenger, such as name, emergency contact 

person/phone number, age or age category, and gender. The information would be available as a 

printed manifest on board the train and in a computer database located elsewhere to provide 

redundancy in case the onboard manifest is destroyed or cannot be located after an accident. 

4.1.2 Types of Train Riders and Ticketing Procedures 

The Arrow CRS is the source of printed train manifests. Passengers may make a reservation by 

calling Amtrak’s 800 number, by using Amtrak’s Web site, or through a travel agent. The 

customer is charged for the ticket (i.e., purchases the ticket at the time the reservation is made). 

Tickets can then be picked up at a station ticket counter or ticket machine later. Walk-up ticket 

purchases at a ticket counter or ticket machine simultaneously make a reservation (if space is 

available on the desired train) and generate a ticket sale and a ticket. The Arrow CRS is updated 

to indicate that a person has picked up his or her ticket. 

Several types of revenue and non-revenue persons also ride Amtrak reserved trains but do not 

make use of the Arrow CRS before boarding and hence are not on the manifest. Instead, their 

presence on board is recorded on various forms that are added to the conductor’s ticket pouch. 
12

Among the non-CRS train riders are passengers purchasing tickets on board, users of monthly 

and multi-ride tickets or passes, non-fare paying infants and small children, railroad and 

government officials (such as FRA inspectors), Amtrak and host railroad employees using passes 

to travel, and passengers who ride past their intended departure station and are issued a ticket on 

board to go back. 

Amtrak policies and procedures are moving toward having fewer cases of non-Arrow riders (e.g., 

by having reservations and sales transactions include non-paying infants). Infants are now issued 

$0 value tickets.15 When pre-purchased, every person on the train in a family gets his or her own 

ticket (all are named) though if purchased on board, this is not the case. Amtrak’s timetables and 

Web sites inform passengers that “reservations are required” for reserved trains, and “substantial 

penalties” are charged when a passenger could have bought the ticket from an open staffed 

station.16 

Except for working or deadheading crewmembers, all Amtrak employees and family members 

using passes must have a ticket for reserved trains, and they may not be able to travel on certain 

trains on certain days. They may have to pay a portion of the lowest available fare and would 

appear on the manifest. Employees of host railroads must also get a free ticket by presenting a 

railroad order. The degree to which these policies and rules are followed was not determined, 

and it is possible that users of employee passes may board without reservations on trains known 

to have excess capacity and then simply be processed using onboard ticketing and ridership 

accounting procedures. 

Still, absent a substantial change in its policies and procedures some riders will always board 

trains without an Arrow reservation and hence are not reflected on printed manifests. In 

particular, allowing onboard ticket sales to persons without reservations is a long-standing, 

institutionalized Amtrak practice. The large number of un-staffed stations and the inclination to 

generate additional revenues from persons who lack reservations are important reasons for this 

practice and would make it difficult to change. Other passenger-friendly practices, such as 

transporting passengers back to their intended destination, and honoring tickets and multi-ride 

passes of commuter railroads operating over the same trackage, are also traditions that create 

exceptions to having Arrow records for all persons on board a train.17

4.1.3 Boarding Procedures

It is important to understand Amtrak’s boarding procedures and related business practices since 

they affect passenger accounting and options for its improvement. The descriptions below are 

based on conversations with Amtrak staff and field observations at NEC stations. 

 

15 Amtrak’s online reservation system now makes provision for children under 2 (non-fare-paying passengers). 

16The substantial penalty is either $9.00 or 50percent of the fare, whichever is less. 

17Amtrak generally has agreements under which it derives revenue from the commuter railroads when it honors 

tickets or passes from their riders. 
13

On Thursday, November 20, 2003, passenger-boarding procedures at Amtrak’s South Station, 

Boston were observed. The boarding of a reserved train (Acela Express 2163, 11:15 a.m. 

departure) and an unreserved train (Regional 173, 11:35 a.m. departure) were observed. Both 

procedures were identical. 

South Station is the Northern terminus of the NEC. The station has stub end platforms. 

Platforms are on the same level as the passenger waiting area and are visible through a glass 

wall. 

The platform is cordoned off approximately 30 minutes before departure. Boarding began 

approximately 10 minutes prior to departure. A train’s availability for boarding is announced 

over the public address (PA) system and passengers are requested to have tickets out and visible 

when boarding. All passengers must display a ticket to the station attendant (accompanied by a 

transit system police officer) in order to get onto the platform. No attempt at matching IDs to 

tickets occurred. 

For the most part, only passengers went to the boarding line. Only one meeter/greeter was 

observed accompanying a passenger to the checkpoint. He left the passenger at that point and 

returned to the waiting area. 

About 20-25 minutes before the scheduled departure of the Regional and prior to the boarding 

announcement, one passenger crossed the unmanned cordon line and headed down the platform. 

He returned a few minutes later. Conductors, train crew, and service personnel were on the 

platform at this time to turn back anyone who attempted to board before the announced boarding 

time. 

Boarding procedures were observed again at South Station on May 11, 2004, and they were 

consistent with the earlier experience. Controlled access to the boarding platform by Amtrak 

staff ensures that boarders are authorized to be on the train under current Amtrak policies, though 

this includes persons not required to have reservations and tickets (e.g., passholders). 

On Monday, November 24, 2003, passenger-boarding procedures at Amtrak’s Back Bay Station, 

Boston were observed. The boarding of a reserved train (Acela Express 2163, 11:20 a.m. 

departure) and an unreserved train (Regional 173, 11:40 a.m. departure) were observed. Both 

procedures were identical. 

Back Bay is an intermediate station on the NEC. Unlike South Station, the passenger waiting 

area is at street level while the platforms are on a lower level. The platform used for Amtrak 

southbound trains is shared with commuter rail operations. 

Unrestricted access exists to the platforms via stairs, escalators, and elevator. A number of 

meeter/greeters were in evidence for both departures. Tickets were not checked on the platform 

prior to boarding and did not appear to be checked inside the train prior to departure. The 

objective of the boarding process seems to be aimed at minimizing station dwell time and 

staffing. 
14

Amtrak staff noted that tickets are checked before boarding only at large stations (e.g., South 

Station, New York, Philadelphia, and Washington in the NEC) primarily for security purposes.18 

The approach used at Back Bay Station (i.e., not checking tickets until they are collected on 

board) is more typical. Moreover, all doors on a train open and close at each station unless the 

train is too large to fit the platform. All Acelas have six cars but only a conductor and an 

assistant conductor, and thus at most stations no means of checking passengers to see if they 

have tickets before boarding under current procedures and staffing levels exists. Regional trains 

may have an additional assistant conductor, but may also have more than six cars. Thus, except 

at a few major stations, it is possible to get on a reserved train without a ticket and without a 

reservation. 

Conclusion Regarding Boarding Procedures 

Except at a few major stations, it is possible to get on a reserved train without a ticket and 

without a reservation. At the many staffed and unstaffed stations with open platform access, 

ensuring that all boarders are authorized would require a change in business practice that adds to 

dwell time and/or staffing, and costs. Further, restricting train access to persons with tickets 

would require abolishing onboard ticket sales and other passenger-friendly practices, or else it 

would not result in accurate passenger accounting. 

4.1.4 Conductor’s Ticket Pouch 

Conductors sweep the train between stations to collect tickets and to ensure that all persons on 

board have either paid or have other authorization to be on board. Tickets collected along with 

records for unticketed persons on board are put into the conductor’s ticket pouch. The pouch 

contains: (1) ticket stubs collected by conductors at each station stop (lifted tickets); (2) Form 

3085s (to the extent conductors follow prescribed procedures for any onboard ticket sales and 

unticketed, non-revenue passengers);19 (3) cash fare receipts; and (4) the form “Record of 

Tickets Honored but Not Lifted.”20 Tickets in the pouch are generally sorted in stop order of 

collection, but there is no form that the conductor uses to summarize the number of tickets lifted 

 

18 Telephone conversation with Rich Reccardi, Human Resources Officer, March 25, 2004; and Conversation with 

Hanan Fadel, Boston Trainmaster, May 11, 2004. 

19The conductor should completed Form 3085 for individuals either buying tickets on board or who are not required 

to pay a fare and are traveling without a ticket. Form 3085 was developed as part of the procedure to be followed on 

reserved trains to ensure that the conductor’s ticket collections pouch provides an accurate list of everyone on board 

who may not be ticketed or appear on the manifest, and to ensure that reserved trains have a passenger manifest that 

is maintained and updated at all staffed, enroute boarding points. The procedure was developed in an attempt to 

respond to NTSB recommendations. See Appendix B for details on the format and use of Form 3085. 

20The form “Record of Tickets Honored but not Lifted” also goes into the ticket pouch. The form indicates the 

number of passengers by class of travel (Coach, Sleeper, Parlor) and their origins and destinations. An Amtrak 

passholder boarded the Acela on the observation trip from Boston to Providence. The conductors accounted for the 

passholder on this form, rather than by means of a Form 3085. In practice other cases besides passholders that are 

accounted for on this form would include passengers with monthly passes from commuter railroads that are honored 

by Amtrak, employees of other railroads (although they should have a Form 3085), and passengers making a 

stopover. 
15

or issued after each station stop.21 The pouch stays on the train until the final destination and is 

then sent to Revenue Accounting. The conductors generally keep the pouch with their personal 

belongings. No standard designated safe place exists on the train for storing the conductor’s 

ticket pouch. 

Amtrak’s Service Standards Reference Manual for Management Employees22 describes the 

procedures that must be followed on long-distance, overnight, reserved trains to ensure that the 

conductor’s ticket collections pouch23 provides the source for an accurate list of everyone on 

board who may not be ticketed or appear on the manifest. Appendix B includes a copy of the 

relevant section of the manual. Appendix C includes a sample of the passenger accountability 

documents discussed below along with the face of the ticket pouch envelope and its associated 

instructions. 

Although Amtrak has written policies to discourage but not prohibit onboard ticket sales, normal 

practice is for conductors to sell tickets on board reserved trains as long as the passenger has an 

acceptable form of identification and space is available. 

The conductors are responsible for the ticket pouch and for informing other crewmembers on the 

pouch’s location. The ticket pouch is supposed to be kept in a place that provides protection 

from heat, water, or impact damage in the event of a train emergency. 

The pouch itself is just a large paper envelope. On an Acela Express, the conductor has an office 

with a rail phone on the café car usually located near the middle of the train. This is where the 

pouch is kept, along with the conductor’s bag with all required forms, timetables, and emergency 

procedures manuals. No specially designed protective location exists within the office for the 

pouch. The Regional trains do not have an office, and the conductors generally operate out of 

the café car. 

A cash fare receipt is issued for onboard ticket sales,24 and, according to Amtrak policy, the 

conductor is also required to issue a Form 3085 for each individual in the party. In practice, this 

 

21No set system for ticket pouch management exists. On a trip on an Acela Express from New York to Boston, the 

conductor had not bothered to sort tickets because it was a light load, and she felt that if necessary she could sort and 

count the tickets rather quickly. She indicated that she also worked the Regional trains (with more stops), and when 

the load was heavier, she used a more rigorous system of keeping the tickets sorted by origin and destination. 

22 Amtrak, Service Standards Manual for Train Service & On-Board Service Employees, Chapter 16, “Train Service 

Crew Functions & Accountabilities,” Part D, “Passenger On-Board Record Procedures,” May 3, 2004. 

23Technically it is Form NRPC 158, the “Train Collections Pouch.” Hereafter it will be referred to simply as the 

“conductor’s ticket pouch.” 

24Tickets are sold on board as long as the passenger has a photo ID. If the passenger does not have an ID, he or she 

is asked to leave the train, and this happens but not often. If the ticket is sold, the passenger pays the regular fare 

plus a penalty if the ticket is purchased at a time when the ticket office at the passenger's origin station is open. If 

the ticket was paid for via the reservation system but not picked up before departure, the passenger pays the 

difference, that is, the penalty portion. On trains operating within the NEC, the conductor would call the last station 

to verify that the unticketed person had a reservation and had paid if he or she did not appear on the conductor’s 

version of the manifest as an unticketed passenger. 
16

does not always happen. A system-wide audit would be required to find out the extent to which 

the policy was being followed. The cash fare receipt has the dollar amount, the number of 

passengers in the party, and origin and destination. One receipt is issued per family or party 

traveling together. In practice, it does not show all names.25 If one of the party was an infant, a 

Form 3085 would be issued for the infant. These receipts never get into the Arrow system but 

are tallied by revenue accounting after the fact along with all other tickets collected.26

Form 3085 is used for each passenger or rider who is not ticketed before boarding. It is issued 

for riders purchasing tickets on board, infants, and Amtrak and host railroad pass-holders on nonwork related trips. Employees deadheading as part of a job assignment are accounted for 

separately in the crew manifest. The original of each Form 3085 goes into the conductor’s pouch 

and the other copy should be dropped at the next open station for entry into the Arrow system 

and updating of the train manifest. Form 3085s are used on Acela Express and all long 

haul/overnight trains. It is Volpe Center’s understanding that they are no longer used on 

Metroliners or NEC reserved Regional trains because, given the large numbers of pass holders 

on these trains, it would take too long to do a Form 3085 for all pass holders. 

The consensus of the Amtrak officials interviewed27 was that the ticket pouch, rather than the 

printed manifest, was currently the best (but not perfect) source of passenger count information 

because it excludes no-shows and includes persons who board without tickets. 

Conclusions on Use of Ticket Pouch for Passenger Accounting 

• Even if Amtrak policies are followed, the ticket pouch is not a perfect passenger 

accounting system since: (1) a time lag to “sweep” the train and gather the records exists, 

during which the pouch does not contain complete records of persons on board; (2) the 

conductor could miss someone when collecting tickets; (3) a passenger could leave the 

train before his or her scheduled stop without notifying the conductor either because of a 

personal emergency or last minute change in travel plans; and (4) in an accident the 

pouch could be destroyed or lost. 

• In actual practice, the ticket pouch records are not likely to be an accurate basis for 

passenger accounting due to the failure to use the Form 3085 consistently. As noted, 

exceptions are permitted on some reserved trains in the NEC, and, given their limited 

 

25The receipt does provide space for at least one passenger name, address, and phone number. The name of the 

person paying for the ticket is included on the receipt. 

26The conductor gives a copy of the receipt to the passenger and puts a copy in the ticket pouch. The conductor 

keeps a copy since he or she is accountable for all tickets missing from the book he or she was issued. Serial 

numbers on coupons are tracked since these coupons are considered by Amtrak to be the same as cash. The final 

copy is turned in with the cash or credit card slip to the ticket office at the end of the run. This is the revenue pouch, 

which may be a plain envelope or just a collection of loose paper and cash. No formal revenue pouch exists. 

27Telephone conversation with Ed Mruk, Amtrak Systems Service Trainmaster, March 24, 2004; telephone 

conversation with Rich Reccardi, Human Resources Officer, March 25, 2004; telephone conversation with David 

Nogard, Senior Director of Service Delivery, April 5, 2004. 
17

perceived value and importance relative to other conductor records and responsibilities, 

lapses in the use of Form 3085s in other situations seems likely. 

• Regarding passenger identification, since the cash fare receipts lack passenger name 

information for multi-person groups traveling together, unless the conductor also fills out 

a Form 3085 for each individual (and, as noted, this process is not uniformly followed), 

incomplete records of individual names will exist. The same is true of the Record of 

Tickets Honored but not Lifted as it is applied to revenue pass holders (i.e., any failure to 

use the Form 3085 results in missing passenger names). 

• No designated or specifically designed safe place exists on board for the ticket pouch. 

Given the possibility that the pouch would be destroyed or be inaccessible in serious 

accidents (and it is mainly the serious accidents that accurate passenger accounting is 

needed), a need exists for having some means of transmitting all of the information in the 

pouch (tickets actually lifted, onboard ticket sales receipts, Form 3085s issued after each 

station stop, and the “Tickets Honored but Not Lifted” form) to a safe repository off the 

train, to use this information to update Arrow so it can become a source for an accurate 

count of on/offs by station, and provide an accurate name list of passengers on board at 

any given time. 

• No standard procedures appear to be in place regarding ticket pouch management, that is, 

sorting all tickets and forms by origin/destination or summarizing ons and offs after each 

station stop. This means that, while the pouch may contain most of the information 

needed to determine the number of passengers on board, the work involved in sorting 

through the individual pieces of paper precludes determining an accurate count of 

passengers on board in a timely manner, and would be a daunting task to someone 

unfamiliar with the various forms and their uses if the conductor was unavailable. 

4.1.5 Amtrak’s Printed Train Manifests and Arrow CRS 

Under Amtrak’s current policies and practices, its Arrow reservation and ticketing system is used 

to create printed train manifests about 30 minutes before departure and crew changes. An 

Amtrak train manifest provides the train crew with the number (but not names) of all revenue 

passengers getting on and off at each station, the names of first class and sleeper passengers, 

train consist information, and special needs and group information. The passenger manifest does 

not include non-revenue unticketed passengers or working crew.28 

Travel agents are tied into the Arrow CRS, and their ticket sales are reflected on the manifest, 

though subject to the same limitations noted for other Arrow users. 

The manifest contains different types of information for different types of passengers. The 

following information is based on an Amtrak training manual, a sample manifest provided by 

Amtrak, the field trip observation, and conversations with Amtrak staff. For coach passengers 

 

28A separate manifest for the crew exists and can be considered a supplement to the passenger manifest for purposes 

of accounting for persons on board. 
18

the manifest only shows the number of reservations for passengers getting on and off at each 

station. It does not show passenger names even though that information is contained in the 

Arrow database and can be printed out. It was noted that a name list of coach passengers has no 

routine value or use to conductors and would be voluminous for trains with large numbers of 

passengers. For first class passengers the manifest lists the name of the passenger, their origin 

and destination, and whether or not they have picked up a ticket. For sleeping car passengers, it 

includes all of the information for first class passengers plus an actual room assignment. For 

group travel (minimum size is 20), the manifest lists the number of people in the group but not 

individual names.29 Appendix A shows sample manifest information. 

The manifest also provides a list of persons with reservations but for whom tickets have not been 

issued; it is used by conductors in issuing tickets on board. The conductor makes no attempt to 

match names on the unticketed list to names on the tickets he has collected to determine whether 

everyone on the reservation list has in fact boarded the train.30 The conductor does not attempt 

to reconcile the reservation list with tickets collected, tickets sold/purchased on board, or Form 

3085s issued for children and employees. 

Because the initial manifest31 is printed 30 minutes before departure from the train’s origin, it 

does not include tickets purchased in the last 30 minutes prior to departure, nor does it include 

transactions made after departure (e.g., tickets purchased on board without prior reservations, or 

reservations made or tickets purchased after departure for boarding at downstream stations even 

though these are common given the extended operating time of most intercity reserved trains). 

Thus, the printed manifest the conductor has on board the train will generally be incomplete. It 

also will contain no-shows, (i.e., persons with reservations who do not actually board the train) 

because conductors do not check persons boarding against the manifest listing. 

Passengers may depart the train before their ticketed destination station for any number of 

reasons including ticketing errors, changes in travel plans, illness, and even unruly behavior. 

The Amtrak Service Standards Manual specifies onboard accounting procedures the conductor 

should follow if aware of these situations, but the open Amtrak system for boarding and 

deboarding does not ensure that the conductor will know of all such cases and perform the proper 

accounting, and no provision exists for updating Arrow with this information. Arrow and the 

train manifest treat the passenger as if he or she is on the train until his or her destination station 

is reached and thus will not be accurate when exceptions occur. 

 

29Amtrak, How to Read a Train Manifest, revised March 2004. 

30On a trip from Boston to Providence and return (May 11, 2004), it was observed that the conductors made an 

announcement over the PA system requesting passengers to sign their tickets in the upper right hand corner before 

they were collected. Trainmaster Hanan Fadel confirmed that this was standard procedure on NEC trains. All 

Amtrak issued tickets are signed to verify that it belongs to the person holding the ticket. Passengers are not 

required to show an ID at this time because they had to show an ID when picking up the ticket. (A photo ID is not 

required if the ticket is picked up at a ticket machine.) 

31 The next subsection discusses updates, which apply more to the Arrow database than to the onboard printed 

manifest, which is typically only updated at crew change points. 
19

The printed manifest is a predeparture reservation listing and is an inexact source of actual 

passenger counts since it excludes persons who enter the system after the train departs, includes 

persons with reservations and tickets who do not actually board the train (i.e., no-shows), and 

does not reflect the possibility that passengers depart at stations other than their ticketed 

destination. 

Arrow and Manifest Updates during Train Runs 

According to Amtrak policy and directives, the Arrow database and the manifest derived from it 

are updated as the train progresses. In the ideal world the conductor issues Form 3085s to 

persons without an Arrow reservation,32 and at the next open staffed station drops off one copy 

of each Form 3085, which is then used to update the Arrow database by the station staff. At the 

next downstream staffed station the conductor would leave the train, enter the station, and either 

get a updated manifest from station staff or use a computer terminal to print it out. The updated 

manifest that the conductor would obtain at this point would include the Form 3085 updates 

provided at the prior staffed station, and any additional reservations made to the Arrow system 

since the last manifest was printed. It would also omit some no-shows (i.e., those where the 

ticket was not picked up by the purchaser by the time of departure) though, in fact, these could 

be passengers with reservations who purchased tickets on board. However, even the updated 

manifest would not account for onboard ticket sales (and any other Form 3085s created) since 

the Form 3085s were dropped off at the previous station for entry into Arrow nor for any new 

unticketed boarders at this station stop. 

It seems for logistical and practical reasons, however, that even the ideal update process does not 

occur as described. The update process is based on the Form 3085s, but from both Volpe 

observations and discussions with Amtrak staff, it seems that the Form 3085s are not prepared 

for all persons boarding without reservations and tickets. In part, this occurs because conductors 

do not view it as important in cases where no revenues are involved. Their primary 

responsibility is to assure that ticketing occurs for those who should be revenue passengers. 

Form 3085 is redundant for passengers issued tickets on board, and has no other use to 

conductors except in the unlikely event of an accident. In addition, in cases where many 

monthly passes or multi-ride tickets are involved, the extra work involved can be viewed as 

excessive, especially if the next station stop will occur soon or on trains with large numbers of 

such passengers, and Amtrak policy recognizes this as a sanctioned exception to their use on 

Metroliners and reserved Regional trains in the NEC. 

The second major discrepancy from the ideal is that the station drop-off for entry of Form 3085s 

into Arrow and the pickup of updated manifests is inconsistent with the practice of having short 

station dwell times and the physical layout of many stations. Conductors assist passengers in the 

deboarding and boarding process and thus leaving the platform area would often disrupt this 

function, especially because at some stations ticket offices are some distance away and 

 

32There are two exceptions: (1) Form 3085 is not used for passholders and onboard ticket sales in the NEC; and (2) 

a relatively infrequent exception exists when a person goes beyond their intended destination and boards a train to 

be carried back. Though this exception could be easily eliminated with a change in policy, it would have no 

practical consequence since the person would generally be off the train before the 3085 information could be added 

to Arrow. 
20

sometimes even on other levels or platforms. Amtrak policy explicitly includes a waiver from 

following the update procedures at staffed stations where the office is not readily accessible from 

the train platform or when the process would delay the train. It can be surmised that 

considerable variation probably occurs in the degree to which the manifest update process 

follows the ideal. 

Typically, an updated manifest would be printed and brought on board when the conductor is 

relieved at the next crew change point, if any. This revised manifest, would suffer from the same 

deficiencies as the original; namely, it would not include passengers boarding without a 

reservation, passengers purchasing tickets without a prior reservation in the last 30 minutes 

before departure from the crew change point, or reservations being made and tickets sold for 

departures from stations downstream from that point. It would however omit some no-shows 

where the ticket was not picked up by the purchaser by the time of departure at prior stations. It 

would still consider all issued tickets as boarded passengers even if they were no-shows. In 

general, even a revised manifest will not contain all of the information about persons on board in 

the conductor’s ticket pouch. 

Conclusions Regarding Amtrak’s Arrow CRS and Manifest System 

• Due to the many exceptions arising from special cases and Amtrak policies and practices, the 

printed manifest on board trains does not meet the objectives of the NTSB recommendation 

on passenger accounting. To remedy this, the following would need to occur: (1) a means of 

transmitting all of the information about who is actually on the train–purchased tickets 

actually used, onboard ticket sales, tickets honored but not lifted, and other Form 3085 

cases–into the Arrow CRS; (2) a means to convert this information into an accurate count of 

on/offs by station and an accurate name list of all passengers on board at any given time; and 

(3) a means to provide a printed copy of this information on the train. 

• At best, the current manifest provides an estimate of what the crew may expect in terms of 

workload on their tour of duty, information on passengers with special needs, and 

information on groups.33 It also provides an incomplete list of unticketed passengers holding 

valid reservations. It does not appear to be used by the crew for any passenger accounting 

function, likely because of the limited and outdated information it contains at any point in 

time. 

The current train manifest system of passenger accounting suffers from the following limitations. 

• Passengers making reservations or picking up tickets (either at ticket machines or ticket 

counters) after the train’s 30-minute predeparture window at the origin or downstream 

stations do not appear on the train manifest. Moreover, using their predeparture printed 

version of the manifest there is no way for the conductor to verify that the passenger without 

a ticket has made a reservation (and paid) after the train’s 30-minute predeparture window, 

but not picked up his or her ticket. 

 

33This was the consensus opinion of the train master and conductors interviewed on a trip from Boston to 

Providence and return (May 11, 2004). 
21

• It incorrectly includes persons not on the train (no-shows, specifically people who were 

issued but do not actually use their ticket), and persons departing from the train before the 

ticket destination. If a ticket is issued, Arrow assumes it is used and that the passenger 

remains on the train until his or her scheduled destination. If a ticket is not issued by the 

scheduled time of boarding, the Arrow system will delete a person from the train manifest 

database, and the updated manifest provided at the crew change point would reflect this. 

• The manifest does not account for Form 3085 updates in a timely fashion, and the system for 

getting the Form 3085 information into Arrow, and for the conductor obtaining an updated 

manifest, is unreliable. The current system of relying on staffed station’s drop-offs and 

pickups is not adequate even if it worked perfectly because of the large gaps between staffed 

stations on many routes and because it would always be at least one station behind in terms 

of completeness. The existence of many unstaffed stations exacerbates this problem. 

• Amtrak-sanctioned exceptions exist for using Form 3085 for some reserved trains and classes 

of riders, and it seems prone to unsanctioned omissions in other situations. To this extent, 

even the properly updated information in Arrow and any manifest created from it will not 

always be accurate. 

• No way of comparing who actually got on the train with the information on the typical 

manifest exists. Under current practices the manifest lacks passenger information for coach 

passengers (name).

4.1.6 Conclusions on Amtrak’s Existing Passenger Accounting Systems 

• Amtrak’s current passenger accountability system does not and cannot meet the NTSB’s 

requirement for accurately knowing the number and identity of passengers on reserved 

trains at all times. 

1. The Arrow CRS does not have access to information about the number or identity 

of persons who actually board and depart Amtrak trains and as a result includes 

persons not on board (mainly no-shows) and excludes persons boarding without 

prior reservations. 

2. The conductor’s ticket pouch has records from which a better list can be 

developed, but due to various exceptions and time lags it cannot be considered 

100 percent accurate, and it suffers from the possibility that it could be destroyed 

in an accident with no reliable backup system for the information it contains. 

• The ticket pouch system can be improved through strict implementation of the policy 

requiring the issuance of a Form 3085 for passholders, other non-ticket riders, and 

individuals purchasing tickets on board all reserved trains, though staffing levels might 

need to be increased on trains with large numbers of such cases. It would remain an 

imperfect system for reasons described elsewhere. 
22

• The process of dropping off records at staffed stations for entry into Arrow and creation 

of updated manifests is inherently flawed, even if the sanctioned and unsanctioned 

exceptions to following the prescribed process are overlooked. 

1. No practical way exists to identify no-shows so Arrow will continue to include 

these persons in any list developed. 

2. The update process will always be at least one station behind since the Form 

3085s are created as part of the conductor’s train sweep after the train leaves the 

station. 

3. Other cases that can cause discrepancies, such as premature train deboardings 

though probably less common, cannot be completely discounted. 

• Printed manifests that conductors have on board trains suffer from the same deficiencies 

as the Arrow system from which they are generated, are further out-of-date, and in 

practice lack the names of coach passengers. 

• The ticket pouch accounting and Arrow update process involve a number of manual steps 

that can easily be omitted or performed in ways that create errors and information gaps, 

thus reducing their effectiveness for passenger accounting purposes. In addition to the 

system’s inherent flaws, its execution is prone to error. 

To completely correct these deficiencies would require substantial changes in policies, business 

practices, and the technology used in processing passengers. Among its characteristics would be 

requirements that all boarding passengers must have a ticket or pass containing their identity 

before boarding (i.e., no onboard sales or other exceptions), that these tickets are checked as part 

of the boarding process, and that the number of passengers boarding and their identity is made 

available to Arrow before the train departs from the station. 

In addition, all departing passengers would need to have their tickets checked/validated, so that 

the number of passengers departing the train and their identity is made available to Arrow before 

the train departs the station. 

4.2 Past Initiatives to Improve Amtrak’s Passenger Accounting System 

Amtrak has undertaken several initiatives that would improve its systems for accounting for 

passengers on board. Following the September 1993 Amtrak accident in Mobile, Alabama, 

NTSB recommended that Amtrak do the following: 

R-94-7

Develop and implement procedures to provide adequate passenger and crew lists to local 

authorities with minimum delay in emergencies. 

Amtrak responded to the safety recommendation on July 18, 1995, stating that a three-phase 

project to provide a satellite and messaging system between long-distance trains and the 

corporate entities associated with their operation would be implemented. According to Amtrak, 
23

Phase I would develop and install a test version of the system, Phase II would expand the system 

to more trains, and Phase III would provide nationwide voice communications. 

In connection with its investigation of a derailment of Amtrak Train 4 near Kingman, Arizona, in 

August 1997, Amtrak’s General Manager for Operations, Standards, and Compliance told NTSB 

that Amtrak had a contract with a service to provide a satellite-based communications system 

known as Star Trak. The system was about 75 percent installed. It consisted of a satellite 

communications unit in the body of the train that can permit portable two-way communications 

between the train and Amtrak’s national operations center. The locomotive would have a laptoptype computer, and the conductors would be able to communicate through the locomotive’s 

computer and antennae. This communications system would be independent of the locomotive 

radio for communicating with the host railroad’s train dispatcher for train operations. Amtrak 

was next going to develop a method to use the system to account for passengers on the train. 

On March 24, 1998, Amtrak demonstrated its Star Trak satellite communications system for 

NTSB investigators. The system included an onboard mobile communications terminal in the 

locomotive, a conductor’s portable unit, and a global positioning system (GPS) locator for the 

locomotive. The system demonstrated that Amtrak had the ability to communicate, 

independently of a host carrier, with its own trains anywhere in the United States (with certain 

exceptions, such as tunnels). The system is programmed to accommodate 19 preformatted 

messages for train status and direct communications between the train and its national operations 

center. It also provided communications between the train and Amtrak maintenance and 

customer service personnel. It had no onboard printing capability. In addition, if the locomotive 

unit loses power, the onboard computer will not work.34 

The General Manager for Operations, Standards, and Compliance also stated that, in past 

accidents and incidents, Amtrak personnel have had to search for the conductor’s pouch to count 

the tickets to determine the number of people on the train. The General Manager had prepared a 

draft policy to change those procedures, and Amtrak had established a working group to ensure 

that an official passenger count is provided to the national operations center. Under the proposed 

system the official count would include ticketed revenue passengers (including multi-ride pass 

holders) and non-revenue non-ticketed passengers such as infants, Amtrak employees traveling 

on a pass (regardless of travel status), employee dependents, and authorized employees of a 

railroad over which tracks Amtrak is operating. 

According to the General Manager, the plan was for Amtrak to use the satellite communications 

system to download Arrow data onto a form in the onboard computer. Each train conductor 

would then add to the form some information about the number of people on board each train, 

and the information would be transmitted using the communication system back to the national 

operations center and would be immediately available to other Amtrak personnel. He also stated 

that, after the process had been tested satisfactorily, it would be implemented on all reserved seat 

 

34Railroad Accident Report Derailment of Amtrak Train 4, Southwest Chief, on the Burlington Northern Santa Fe 

Railway near Kingman, Arizona August 9, 1997 (Revision August 7, 2003), NTSB Report Number RAR-98-03, 

adopted on 8/31/1998. 
24

trains. While the Star Trak communication portion of the system is in use, the passenger 

accounting portion of the system was never implemented. 

On September 14, 1999, the president of Amtrak Intercity testified during NTSB’s public 

hearing on the Bourbonnais, Illinois, accident that in 1998 Amtrak had made an investment of 

$24 million and contracted with Motorola to develop an automated system for onboard 

accounting of train passengers. It was to replace the onboard manual ticket collection and 

payment system. The computerization of many tasks and the introduction of smart cards was 

supposed to make the system more efficient for customers and conductors, who would be able to 

devote more time to customer service. 

He described the system as having a simple handheld device (HHD) to be used by the conductor 

to scan the tickets and record a passenger’s name. Conductors were to use the HHD configured 

with the train’s passenger manifest to read the ticket barcode, process ticket sales using credit 

cards, checks, cash or smart cards,35 and issue a receipt or seat check utilizing a separate printer 

that fits on the belt. As proposed, the information captured by the HHD would be transmitted to 

an Onboard Computer (OBC) via a HHD docking station. Once the train reached a designated 

station, the data would be transmitted via wireless local area network (LAN) technology, to a 

Station Information Computer (SIC), which would in turn be linked to Amtrak’s Arrow CRS. 

Ultimately, data was to be transmitted while the train was in motion, not at designated stations, 

via a wide area wireless communications network. In this way, the passenger count data could 

be made available to emergency responders. The Amtrak official said the system was scheduled 

for implementation in 2000. 

The new system was also to give Amtrak more accurate and timely ridership and revenue data, 

as well as significantly improve its management of seat inventory, helping to generate additional 

revenue. Real time passenger manifests were to permit the sale of cancelled reservations or sale 

of seats of ticketed passengers who did not board the train and were to assist accident responders 

by giving a better accounting of who and how many were on board the train. 

The contract also called for Amtrak and Motorola to test two smart card applications and 

eventually roll them out system wide. In one pilot project, frequent customers of Acela Express’ 

first-class service would be able to use the Motorola M-SmartTM smart card as an e-ticket. In 

another pilot, the smart card would be used to track onboard meals on Amtrak’s long-distance 

trains.36 

However, Amtrak did not implement the Motorola passenger accounting system. Early in 2003, 

an Amtrak official stated in a letter to an NTSB staff member: 

While Amtrak continues to explore realistic technological alternatives to enhance 

the efficiency of recording ticketed and non-ticketed passengers, we feel that the 

 

35Smart cards are credit card-sized devices embedded with a computer chip that can accept, store, and send up to 100 

times more information than traditional magnetic-striped cards. 

36http://www.motorola.com/LMPS/pressreleases/CGISS9949.html
25

passenger accountability system presently in place is a reliable one. 

Amtrak, therefore, still uses the paper onboard record system outlined in its Service Standards 

Manual for Management Employees to account for passengers on its long-distance, overnight, 

and reserved trains and has abandoned prior initiatives to replace it. 

The Amtrak officials interviewed provided several reasons as to why the Motorola effort was 

abandoned by Amtrak. One person said it was dropped because it could not provide real time 

information. Another noted that transmitting the data from the train to a central database was the 

problem at the time. Amtrak’s aspirations were much greater than what the technology (at that 

time) could deliver, and the system would have been extremely costly. Another mentioned that, 

when the system was tested by conductors on board, it was found to be a slow and cumbersome 

process. It reportedly took the conductors about 17 minutes (the interval between stations in this 

case) to use the scanning system to process 8 passengers; conductors should normally be able to 

process about 5 times that number of passengers in that time using manual methods.37

4.3 Amtrak’s Current Initiative to Improve Passenger Accounting 

Amtrak has issued a Request for Information (RFI) to vendors for a system to replace its current 

Star Trak satellite communications system on trains. If successful, this effort would also provide 

the communications system needed to support an automated manifest system. The new system 

would include the following capabilities: 

• automatic train location using GPS 

• two-way voice communications between Amtrak’s operations center and trains 

• onboard fare collection, ticketing, and manifesting 

• possibly mechanical monitoring and transmittal of digitized movies 

The proposed system would report when the train arrives at a station, and the onboard fare 

collection would include real time credit card verification. 

Amtrak’s RFI is asking the venders to tell them the best way of meeting their goals. The RFI 

responses were received from vendors in May 2004. A Request for Proposal (RFP) will be 

issued to vendors before the start of fiscal year 2005 (FY05). It is not anticipated that 

widespread implementation of the new system would occur until FY06 and FY07. 

The primary purpose of this project is to develop a communications backbone for Amtrak (i.e., 

direct communication between the train and Amtrak offices). Currently, Amtrak has no direct 

voice communication link between its operations center and the majority of its trains because 

they are not operated on Amtrak right-of-way (ROW). Trains’ voice communications link 

directly with host-railroad dispatchers but not with Amtrak. 

An automated manifest system would be only one potential use of the communications backbone 

and would be a follow-on development once the backbone was in place. Ideally they would have 

 

37Telephone conversations with Amtrak staff during March and April of 2004. 
26

a two-way flow of information–from the train to the reservation system and back. The conductor 

would be able to get an updated manifest while on board the train. This could be a station update 

or real time update, but the exact approach is still undetermined. 

The system would have to handle all types of onboard transactions, including the following: 

• passengers boarding with a ticket 

• passengers boarding with a paid reservation but without a ticket 

• passengers boarding without a reservation or a ticket 

• recording information on pass holders, employees, and other passengers who 

currently require the issuance of a Form 3085 

Amtrak believes that it is technically feasible to create a communication data link that will 

support onboard fare collection and passenger accounting functions, but many uncertainties exist 

that affect cost. They could need 400 to 800 units at a minimum to equip all trains with a 

communications box. However, they may or may not need a unit on all cars. They have more 

than 2,000 pieces of equipment (1,400 passenger cars plus baggage cars, and diners).38

Onboard system survivability in an accident remains an issue though any system must withstand 

a rugged train environment (temperatures, shock, and vibration). The system might have some 

redundancy with a communication capability from the front (engineer) of the train and the back 

(conductor) of the train. More importantly, since data from on board the train would be 

communicated to a central database, they can be retrieved to provide passenger accounting 

information as a contingency in severe accidents. 

Ticket scanning/collection has been done on Amtrak’s Keystone Service (Harrisburg to 

Philadelphia and New York). A bar code scanner is used to scan tickets, but no real time 

transmission of the data occurs. Information from scanners is downloaded at the end of the line. 

Bar code scanners are a cheap, proven technology. The major problem appears to be that of 

sending data from a moving train to an off-train computer and using it to update the Arrow 

database.39 It is unclear how this system accounts for persons boarding without tickets. 

In addition Amtrak is involved with the CCJPA40 in a joint-effort, pilot program of an onboardautomated fare collection system in Capitol Corridor trains using handheld ticket readers. 

Benefits of this system would include customer convenience, real time information on ridership 

and revenue, and cost efficiencies.41 As proposed, the system would include a handheld scanner 

 

38Telephone Conversation with Chris Jagodzinski, Senior Director of Systems Operations, April 9, 2004. 

39Telephone Conversation with Chris Jagodzinski, Senior Director of Systems Operations, April 9, 2004. 

40The Capitol Corridor Joint Powers Authority (CCJPA) is a partnership among the six local transit agencies in the 

eight county service area which shares the administration and management of the Capitol Corridor.

41http://www.amtrakcapitols.com/ccjpa/business_plan/bp06_fares.shtml
27

that the conductor would use to read the “Arrow” ticket. At some point, the data collected would 

then be transmitted off the train using cellular or wireless fidelity (WIFI) technology.42

Conclusions 

The ongoing initiatives will improve Amtrak’s passenger accounting capabilities if developed 

and implemented as planned. Significant business practice, cost, and technology challenges 

must be overcome, so uncertainty exists as to how effective these initiatives will be. At best, 

however, they seem to be automating Amtrak’s existing ticket lift system, and its inherent flaws 

will remain as imperfections even if implemented and used consistently. The underlying flaws 

are the problems caused by not knowing who has boarded until after the sweep is completed after 

each stop, whether anyone is missed in the train sweep, and whether anyone has departed before 

his or her ticketed destination. 

4.4 Foreign Systems 

4.4.1 Eurostar Service 

Eurostar connects the capital cities of France (Paris), England (London), and Belgium (Brussels) 

through the Channel Tunnel. Each train set has 18 cars-1 in Premium First, 5 in first class, 10 in 

second class, and 2 bar cars. The total seating capacity is 770 seats-205 in first class and 

Premium First, and 565 in second class. Its maximum commercial speed is 186 miles per hour 

on the French part of the system. 

Reservations and having tickets issued before boarding are mandatory. All Eurostar passengers 

must follow a controlled boarding process. Eurostar has extended its minimum check-in times to 

guarantee smooth passage through enhanced security checks. For security reasons, passengers 

must check in at least 30 minutes before the train is scheduled to depart. 

Passengers check in through automated gates if their ticket has a magnetic stripe on the back. If 

it does not, the non-magnetic ticket must be presented at one of the check-in booths. They then 

go through security and passport control before entering the waiting area. X-ray and metal 

detection machines similar to the ones at airports are used. Fifteen minutes before departure, 

doors, which give access to the platform, are opened and passengers can board the train and head 

to their designated car and seat.43

 

42Telephone conversation with Ed Mruk, Amtrak Systems Service Trainmaster, May 7, 2004. 

43http://mercurio.iet.unipi.it/eurostar/ESreport.html

http://lonelyplanet.raileurope.com/us/rail/eurostar/train.html

http://lonelyplanet.raileurope.com/us/rail/eurostar/index.html

http://lonelyplanet.raileurope.com/us/rail/eurostar/service.htm

http://lonelyplanet.raileurope.com/us/rail/eurostar/check_in_times.html
28

In the United Kingdom proposals have been introduced to extend Eurostar services to 

Manchester and Edinburgh. However, a major constraint cited against these proposals has to do 

with problems associated with carrying domestic passengers on international trains. No details 

are provided, but the overriding consideration seems to be security, in terms of countering the 

threat of terrorism, followed by problems associated with allowing Customs and Excise to 

operate effectively, as well as passport control. 

The Eurostar boarding system functions like most commercial airlines, and an exact record of 

passengers boarding is available, but there is a passenger accounting weakness in that no 

monitoring of departures at the intermediate stops occurs. 

4.4.2 British Rail 

British trains (BritRail) are mixed because they are unreserved trains, but for an extra fee one can 

reserve a seat. Except for certain peak periods on certain routes, reservations are not considered 

necessary because of the high frequency of service.44 The BritRail approach would not serve as 

a model for an improved Amtrak manifest system because it lacks a reservation system for all 

passengers. 

4.4.3 Japanese Intercity Passenger Trains 

About 70 percent of Japan’s railway network are owned and operated by the Japan Railways 

(JR), while the remaining 30 percent belong to several dozen railway companies, especially in 

and around metropolitan areas. JR is the successor of the national Japanese National Railways, 

which was privatized in 1987. The JR Group is made up of six regional passenger railway 

companies (JR Hokkaido, JR East, JR Central, JR West, JR Shikoku, and JR Kyushu) and one 

nationwide freight railway company (JR Freight). Together they operate a nationwide network 

of urban, regional, and interregional train lines, night trains, and bullet trains (Shinkansen).45 

From local trains to Shinkansen, Japanese trains are typically classified into the following 

categories: 

• Local-Local trains stop at every station. 

• Rapid-Rapid trains skip some stations. There is no difference in the ticket price 

between local and rapid trains. 

• Express-Express trains stop at even fewer stations than rapid trains. In case of JR, an 

express fee has to be paid in addition to the base fare. 

• Limited Express-Limited express trains stop only at major stations. A limited 

express fee must be paid in addition to the base fare. 

 http://www.eurostar.com/dctm/jsp/subhome/detail.jsp?page=plan_travel&id=09001a5980113466

44http://www.britrail.net/britrail_tips_reservations_content.html

45http://www.japan-guide.com/e/e2019.html
29

• Super Express-Shinkansen are only operated by JR. Shinkansen use separate tracks 

and platforms. A limited express fee must be paid in addition to the base fare. 

JR offers the choice between two classes, ordinary and green (first class), on all Shinkansen and 

limited express trains and a small number of slower trains. Most local trains carry only ordinary 

cars. All seats in green cars are reserved. Most Shinkansen and limited express trains carry nonreserved and reserved seats, while a few carry reserved seats only. On most local, rapid, and 

express trains, all seats are non-reserved. 

 

Tickets for short distance trips are best purchased at vending machines, while tickets and seat 

reservations for long-distance trips can be purchased at ticket counters in train stations. 

 

After buying the ticket, the passenger must proceed through the ticket gate. Automatic ticket 

gates can be found in busy stations. If an invalid ticket is inserted, the gate will close, and an 

alarm will sound. Some platforms are served by trains of different train categories (e.g., local 

and rapid trains). Displays indicate the next arriving train’s category and, at some stations, the 

set of upcoming stations served by it. To access Shinkansen platforms, the passenger must pass 

through a second or separate set of ticket gates. 

Any JR train requires the passenger to purchase a basic fare ticket. Regardless of whether the 

train is fast or slow, this basic amount remains the same. For trains categorized as express trains, 

the passenger must purchase a surcharge ticket for express trains in addition to the basic fare 

ticket. Many different types of express trains exist, ranging from airport express trains to 

Shinkansen trains. An additional first-class car ticket must be purchased for travel in a first-class 

car. 

If the passenger does not have the proper tickets to ride express trains (for example, he or she has 

purchased only the basic fare ticket and boarded an express train), he or she is required to pay the 

express surcharge once on board. If he or she has boarded the wrong train (in terms of 

destination) accidentally and has not purchased the correct ticket, he or she would be required to 

pay the extra basic fare. 

At the destination, the passenger leaves the paid fare zone through the ticket gates in the same 

way he or she entered. If the correct fare for that destination station was not paid, the passenger 

must pay the difference at a Fare Adjustment machine or at a staffed gate before leaving through 

the gates.46

Although all entry and exit from the system is controlled, this is at the platform and station, not 

the specific train. Open boarding occurs on most trains (a passenger can board without the 

proper ticket), the system does not provide accurate passenger accounting even on the allreserved trains, and most trains have non-reserved cars with less potential for accurate passenger 

accounting. It seems that the controlled access functionality is designed to provide accurate 

revenue collection, not passenger accounting. 

 

46 http://www.japan-guide.com/e/e2016.html
30

4.4.4 French Intercity Railways 

The French National Railway’s (SNCF) Passenger Guide was also examined at their Web site. 

There was no description of passenger boarding procedures for SNCF trains or passenger 

manifests, but it did contain a heavy emphasis on ticket validation and inspection procedures. 

Except for the TGV trains, which are all reserved, trains are unreserved, but for an extra fee one 

can reserve a seat. Since the French system has a preponderance of unreserved trains, it would 

not serve as a good model for an improved Amtrak manifest system. 

Conclusions from Review of Foreign Passenger Processing Systems 

Generally, even the relatively sophisticated foreign systems examined do not seem to have 

systems that support accurate accounting of passengers on board. Their systems are focused 

more on accurate fare collection. The Japanese have the only system that requires electronic 

verification at boarding and departing stations, though Volpe Center staff did not ascertain 

whether this information is captured by a database system. The more common business model 

has features that are inconsistent with passenger accounting, namely open access to and egress 

from trains, trains with at least some unreserved cars, and onboard ticket inspection done using 

train sweeps by conductors. It is likely these practices exist for cost and passenger convenience 

reasons.
31

5. Amtrak Accident History 

Amtrak accident and injury information is needed to develop a perspective on the value and 

benefits of an improved passenger accountability system. This section presents summary 

statistics on accidents, injuries, and fatalities. Appendix D provides a more detailed synopses of 

17 accidents, and Section 6 discusses the implications for more accurate passenger accounting 

drawn from these cases. 

Most accidents involving Amtrak passenger trains do not result in passenger injuries or fatalities. 

For the period 1993 to 2003, 92 out of 881 accidents (10.4 percent) resulted in a passenger injury 

or fatality. Most of the other accidents are at highway-rail grade crossings where the primary 

effects are to vehicles and their passengers or pedestrians (i.e., Amtrak passengers do not suffer 

injuries). 

Most reported injuries to Amtrak passengers do not result from a reportable accident (i.e., they 

are slip- and fall-type incidents that do not result from a serious derailment). For the period 1993 

to 2003, only 827 out of 2,572 reportable passenger injuries (32.2 percent) resulted from a 

reportable accident. Significant portions of Amtrak passenger fatalities, however, result from a 

reportable accident. For the period 1993 to 2003, 59 out of 75 reportable passenger fatalities 

(78.7 percent) resulted from a reportable accident. The remaining 16 fatalities (21.3 percent) 

were not the result of a reportable accident. Table 4 presents yearly figures on accidents, 

injuries, and fatalities. All data were obtained from the FRA’s safety database.47

5.1 Accident Data for Reserved versus Unreserved Trains

When individual accidents are examined and the type of train is identified, it becomes apparent 

that overnight/sleeper trains accounted for a disproportionate number of accidents, passenger 

injuries, and fatalities over the period 1993 to 2003. 

Overnight/sleeper trains accounted for 68.5 percent of accidents, 100 percent of passenger 

fatalities, and 84.5 percent of passenger injuries. Yet as shown previously (see Section 3), this 

type of train accounted for about 18 percent of Amtrak ridership, 36 percent of Amtrak routes, 

and 11 percent of trains operated per week. 

The proposed manifest system would apply to these overnight/sleeper trains and reserved trains 

not having sleeper service. These two types of trains combined accounted for 89.2 percent of 

accidents, 100 percent of passenger fatalities, and 94.9 percent of passenger injuries, while 

representing about 42 percent of Amtrak ridership, 77 percent of Amtrak routes, and 46 percent 

of trains operated per week. 

On the other hand, unreserved trains accounted for 6.5 percent of accidents, 0 percent of 

passenger fatalities, and 1.8 percent of passenger injuries, while accounting for about 25 percent 

of Amtrak ridership, 14 percent of Amtrak routes, and 31 percent of trains operated per week. 

 

47 http://safetydata.fra.dot.gov/officeofsafety/
32

The tables in Appendix F provide details on accidents reported by Amtrak, which resulted in a 

passenger injury or fatality for the period 1993 to 2003 by type of service. 

5.2 Accident Details 

Amtrak accidents and the circumstances surrounding those accidents were examined to 

determine whether or not the availability of an accurate passenger manifest would have made a 

difference in saving a person’s life or reducing the severity of injury. Published reports and 

briefs issued by NTSB dealing with accidents involving Amtrak were examined in order to 

accomplish this objective. 

NTSB is an independent Federal agency dedicated to promoting aviation, railroad, highway, 

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

NTSB issues two types of documents: accident reports and accident briefs, based on 

investigations of rail accidents. NTSB’s accident reports contain a fairly detailed description of 

the circumstances leading up to an accident, the outcome (results) of the accident, an analysis of 

all factors involved in the accident, conclusions resulting from the analysis, a determination of 

probable cause, and recommendations for change that NTSB feels would help to eliminate 

similar accidents in the future. 

As the name suggests, NTSB accident briefs contain less detail than its full accident reports. 

NTSB’s accident briefs contain a short summary of the circumstances leading up to an accident, 

the outcome of the accident, the analysis of factors involved in the accident, conclusions 

resulting from the analysis, and a determination of probable cause. 

All 17 reports and briefs for the period 1993 to 2003 dealing with Amtrak accidents were 

examined in the course of this study. Of the 92 Amtrak accidents resulting in a passenger injury 

or fatality that occurred over this period, 10 accidents resulted in NTSB issuing an accident 

report and 3 resulted in NTSB issuing an accident brief. In addition, the NTSB issued reports 

dealing with three other Amtrak accidents that did not result in a passenger injury/fatality. One 

accident report dealing with a commuter rail accident involving passenger fatalities was also 

included.48

 

48 In addition to the report included here NTSB issued nine other reports over the period 1993 to 2003 dealing with 

commuter rail accidents. 
33

Table 4. Amtrak Passenger Casualties 

Year Accidents Involving Amtrak Passenger Trains Amtrak Passenger Injuries Amtrak 

Total 

Resulting in 

Passenger 

Injury/Fatality 

Not Resulting in 

Passenger 

Injury/Fatality Total 

Resulting from 

an Accident 

Other 

Causes Total 

1993 89 11 78 279 139 140 42 1994 81 5 76 112 57 55 2 1995 50 3 47 106 55 51 0 1996 60 3 57 102 15 87 2 1997 70 13 57 241 84 157 4 1998 73 10 63 182 25 157 1 1999 72 7 65 91 45 46 13 2000 99 8 91 294 64 230 3 2001 113 11 102 416 112 304 2 2002 85 15 70 496 203 293 4 2003 89 6 82 253 28 225 2 

Total 881 92 788 2572 827 1745 75 
34

Table 5. Amtrak Passenger Casualty Accidents by Type of Service (1993 to 2003) 

Train Type

Number of 

Accidents Percent

Passengers 

Killed Percent Passengers Injured 

Sleeper 63 68.5% 59 100.0% 699 Reserved 19 20.7% 0 0.0% 86 Unreserved 6 6.5% 0 0.0% 15 Unknown 4 4.3% 0 0.0% 27 Total 92 100.0% 59 100.0% 827 
35

Of the 92 Amtrak accidents resulting in a passenger injury or fatality that occurred over 

the period 1993 to 2003, 5 accidents resulted in at least 1 passenger fatality. NTSB 

issued an accident report dealing with four of these and an accident brief covering the 

fifth. These five cases are listed below: 

• Derailment of Amtrak Auto Train on the CSXT Railroad near Crescent City, 

Florida, April 18, 2002, NTSB Report Number RAR-03-02, adopted on 

8/5/2003. 

• Railroad Accident Brief: Derailment of Amtrak Train No. 5-17 on Burlington 

Northern and Santa Fe Railway Track near Nodaway, Iowa, March 17, 2001, 

NTSB Report Number RAB-02-01, adopted on 3/5/2002. 

• Collision of National Railroad Passenger Corporation (Amtrak) Train 59 with 

a Loaded Truck-Semitrailer Combination at a Highway/Rail Grade Crossing 

in Bourbonnais, Illinois, March 15, 1999, NTSB Report Number RAR-02-01, 

adopted on 2/5/2002. 

• Railroad Accident Report Derailment of Amtrak Train 4, Southwest Chief, on 

the Burlington Northern Santa Fe Railway near Kingman, Arizona, August 9, 

1997 (Revision August 7, 2003), NTSB Report Number RAR-98-03, adopted 

on 8/31/1998. 

• Derailment of Amtrak Train No. 2 on the CSXT Big Bayou Canot Bridge near 

Mobile, Alabama, September 22, 1993, NTSB Report Number RAR-94-01, 

adopted on 9/19/1994. 

The following lists the other 11 Amtrak accidents that were the subject of an NTSB 

report or brief: 

• Collision of Amtrak Train No. 90 and MARC Train No. 437, Baltimore, 

Maryland, June 17, 2002, NTSB Report Number RAB-03-01, adopted on 

5/12/2003. 

• Railroad Accident Report: Rear-End Collision of National Railroad 

Passenger Corporation (AMTRAK) Train P286 with CSXT Freight Train 

Q620 on the CSX Railroad at Syracuse, New York, February 5, 2001, NTSB 

Report Number RAR-01-04, adopted on 11/27/2001. 

• Highway Accident Report: Report of Grade Crossing Accident Regarding a 

Collision Between an Amtrak Train and a Tractor-Trailer Combination 

Vehicle Intercession City, Florida, November 17, 2000, NTSB Report 

Number HAR-02-02, adopted on 7/23/2002. 
36

• Railroad Accident Report: Collision of Amtrak Train 304-26 with a Highway 

Vehicle at a Highway-Rail Grade Crossing in McLean, Illinois, on September 

26, 1999, NTSB Report Number RAR-01-03.

• Railroad Accident Report: Derailment of Amtrak Train 21 on the Union 

Pacific Railroad at Arlington, Texas, December 20, 1998, NTSB Report 

Number RAR-01-02, adopted on 7/24/2001. 

• Grade Crossing Collision, National Railroad Passenger Corporation 

(Amtrak) with Coastal Transport Tractor-Semitrailer, Jacksonville, Florida, 

February 5, 1997, NTSB Report Number RAB-01-01, adopted on 

10/26/2000. 

• Railroad Special Investigation Report Derailment of Amtrak Train No. 12 and 

Sideswipe of Amtrak Train No. 79 on Portal Bridge Near Secaucus, New 

Jersey, November 23, 1996, NTSB Report Number SIR-97-01, adopted on 

12/18/97.

• Collision and Derailment of Maryland Rail Commuter MARC Train 286 and 

National Railroad Passenger Corporation AMTRAK Train 29 Near Silver 

Spring, Maryland, February 16, 1996, NTSB Report Number RAR-97-02, 

adopted on 6/17/1997. 

• Amtrak Train 87 Derailment after Colliding with Intermodal Trailer from 

CSXT Train 176 Selma, North Carolina, May 16, 1994, NTSB Report 

Number RAR-95-02, adopted on 3/21/1995. 

• Derailment of Amtrak Train 49 On Conrail Trackage near Batavia, New York, 

on August 3, 1994, NTSB Report Number RAR-96-02, adopted on 7/11/1996.

• Collision of Amtrak Train No. 88 with Rountree Transport and Rigging, Inc., 

Vehicle on CSX Transportation, Inc., Railroad near Intercession City, 

Florida, November 30, 1993, NTSB Report Number HAR-95-01, adopted on 

5/16/1995.

The commuter rail accident examined in this study was: 

• Collision of Northern Indiana Commuter Transportation District Train 102 

with a Tractor-Trailer Portage, Indiana, June 18,1998, NTSB Report Number 

RAR-99-03, adopted on 7/26/1999. 

Summaries of all of these NTSB accident reports and briefs dealing with Amtrak 

accidents for the period 1993 to 2003 appear in Appendix D. Table 6 summarizes these 

17 accidents. 
37

It should be noted that the numbers for Amtrak passengers injured and killed are as 

reported in the FRA database. These do not match those reported in the NTSB reports in 

all cases. FRA reporting requirements are set forth in the Code of Federal Regulations 

(CFR). The NTSB figures tend to be of a more immediate nature and based on reports by 

emergency responders of the number of passengers transported to a hospital or treated on 

scene, without regard to the nature or severity of injuries. For example, regarding 

fatalities, any passenger fatalities directly resulting from an accident occurring up to 1 

year after the accident are attributed to that accident in the FRA data. Such fatalities 

might not appear in an NTSB report on that accident. 
38

Table 6. Amtrak Accidents Subject to NTSB Reports/Briefs 

Case Location Date Accident Type Result 

Train 

Type 

Number of 

Passengers and 

Crew 

Amtr

Passen

Injur

Collision of Amtrak Train 90 and MARC Train 437 Baltimore, MD June 17, 2002 

Collision-between on track equipment 

Locomotive derailed Sleeper 

141 passengers, 6 crew, MARC-60 passengers, 4 crew 

Derailment of Amtrak Auto Train Crescent City, FL April 18, 2002 Derailment 

Derailed/ overturned Sleeper 413 passengers, 33 crew 

Derailment of Amtrak Train 5 Nodaway, IA March 17, 2001 Derailment Unknown Sleeper 241 passengers, 16 crew Rear-End Collision of Amtrak Train 286 with CSXT Freight Train Q620 Syracuse, NY February 5, 2001 

Collision-between on track equipment 

Derailed/not overturned Reserved 100 passengers, 4 crew 

Collision of Amtrak Train and TractorTrailer Intercession City, FL November 17, 2000 Highway-rail collision/impact Did not derail Sleeper 83 passengers, 4 crew Collision of Amtrak Train 304 with Highway Vehicle McLean, IL September 26, 1999 Highway-rail collision/impact Did not derail Reserved 

number passengers unknown, 3 crew 

Collision of Amtrak Train 59 and TractorTrailer Bourbonnais, IL March 15, 1999 Highway-rail collision/impact Derailed/ overturned/fire Sleeper 207 passengers, 17 crew, 4 employees Derailment of Amtrak Train 21 Arlington, TX December 20, 1998 Derailment 

Derailed/ overturned Sleeper 128 passengers, 18 crew 

Collision of Amtrak Train and TractorTrailer Jacksonville, FL February 5, 1997 Highway-rail collision/impact Derailed/not overturned Sleeper 182 passengers and crew Derailment of Amtrak Train 4 Kingman, AZ August 9, 1997 Derailment 

Derailed/not overturned Sleeper 294 passengers, 18 crew 
39

Table 6. Amtrak Accidents Subject to NTSB Reports/Briefs (continued)

Case Location Date Accident Type Result 

Train 

Type 

Number of 

Passengers and 

Crew 

Amtr

Passen

Injur

Derailment of Amtrak Train 12 and Sideswipe of Amtrak Train 79 Secaucus, NJ November 23, 1996 Derailment 

Derailed/not overturned 

Unknown/ Unreserved 

Train 79-162 passengers, 4 crew Train 12-90 passengers, 3 crew, 24 employees 

Collision and Derailment of MARC Train 286 and Amtrak Train 29 Silver Spring, MD February 16, 1996 

Collision-between on track equipment 

Derailed/not overturned/fire 

Reserved/ Commuter 

164 passengers, 18 crew, MARC-20 passengers, 3 crew 

Collision and Derailment of Amtrak Train 29 and CSXT Train 176 Selma, NC May 16, 1994 

Collision-between on track equipment 

Derailed/not overturned/fire Sleeper 415 passengers, 23 crew 

Derailment of Amtrak Train 49 Batavia, NY August 3, 1994 Derailment 

Derailed/ overturned Sleeper 320 passengers, 19 crew 

Collision of Amtrak Train 88 and TractorTrailer Intercession City, FL November 30, 1993 Highway-rail collision/impact Derailed/not overturned Sleeper 89 passengers, 10 crew Derailment of Amtrak Train 21 Mobile, AL September 22, 1993 Derailment 

Derailed/not overturned/fire /immersion Sleeper 202 passengers, 18 crew 

41

6. Value of an Accurate System for Accounting for Persons 

on Board Amtrak Trains 

There are various reasons why it is desirable to have information about train passengers. NTSB 

contends that one such reason is to provide accurate counts to first responders immediately after 

recent fatal accidents. This section considers the value of such information from a safety and 

resource perspective. 

6.1 Role of Passenger Accounting in Recent Fatal Accidents 

Of the 17 accidents that occurred between 1993 and 2003 and documented by NTSB, 5 involved 

an Amtrak passenger fatality, and 2 involved fatalities on commuter rail trains. In four out of the 

five accidents resulting in at least one Amtrak passenger fatality, NTSB explicitly identified the 

lack of an accurate passenger manifest as an issue in its accident report. 

In one example of its criticism of Amtrak’s passenger accountability system, NTSB has noted 

that 

The survival of passengers and crewmembers might well depend on emergency 

responders, who in turn depend on a complete and accurate accounting of all people 

on the train to ensure that they locate, evacuate, and treat (if necessary) all those on 

board. If the passenger list does not include every passenger on the train, emergency 

responders may leave passengers behind. If the passenger list includes people not on 

the train, emergency responders may be needlessly exposed to prolonged risks as they 

search for nonexistent passengers.49

However, in none of these cases has NTSB explicitly cited an instance where a surviving 

passenger had unknowingly been left behind nor an instance where emergency responders had 

spent time searching for nonexistent passengers. 

The following reviews the seven accidents with fatalities to identify survivability factors 

generally and to explicitly consider whether accurate passenger accounting might have had a role 

in survivability outcomes. 

(1) Derailment of Amtrak Auto Train on the CSXT Railroad near Crescent City, Florida, April 

18, 2002

About 5:08 p.m. on April 18, 2002, Amtrak’s Auto Train, derailed 21 of 40 cars near Crescent 

City, Florida. Of the 21 derailed cars, 8 ended up lying on their sides with the other derailed cars 

remaining in either an upright or leaning position. 

 

49Derailment of Amtrak Auto Train on the CSXT Railroad near Crescent City, Florida, April 18, 2002, NTSB 

Report Number RAR-03-02, adopted on 8/5/2003.
42

Emergency responders were notified immediately following the accident. However, they were 

not told the number of people on the train. The first police unit arrived within 6 minutes, the first 

fire unit within 9 minutes, and the first paramedics within 14 minutes. On-scene incident 

command was established within 11 minutes, and triage and staging areas were established. 

Auto Train onboard service employees told passengers what had happened and that emergency 

services had been called. Some Amtrak employees provided on-scene first aid to passengers. 

Amtrak employees continued to assist passengers and emergency service personnel upon their 

arrival on scene until all the passengers had been evacuated and the site secured. 

The first arriving paramedic reported to Putnam County Dispatch that 468 people were on the 

train; several of whom were trapped, and others who were walking wounded. When NTSB 

investigators interviewed the incident commander after the accident, he said that he had had 

problems getting accurate information from Amtrak about the number of people on the train. He 

said that, soon after he came on scene, the conductor told him that 468 people were on board the 

train and gave him a greeter list.50 The incident commander said that the conductor also gave 

him a passenger list that showed the passengers’ locations by car and room, but the greeter and 

passenger lists did not match. He said that he and other emergency responders spent time 

attempting to verify the accuracy of the two lists. On April 19 (the next day), Amtrak gave him a 

computer printout list with information that did not fully correlate with either of the other two 

lists. 

The incident commander said that he was never provided an accurate count of people on the 

train. During post-accident interviews, the Auto Train conductor told the Deputy Chief of 

Operations for Putnam County Emergency Services that 437 passengers, 3 infants, and 28 

crewmembers, for a total of 468 people, had been on the train. By gathering information from 

Amtrak, Putnam County Emergency Services, and medical records, NTSB investigators 

determined about 5 months after the accident that 446 people had been on the Auto Train when it 

derailed. 

The availability of an accurate manifest was not a factor in preventing the four passenger 

fatalities. All four passengers were partially ejected through the car windows and crushed 

between the car body and track ballast. The fatally injured passengers were dead when found by 

emergency responders. No indication exists that emergency responders spent undue amounts of 

time searching for passengers, or that emergency responders were in danger in searching the 

wreckage. Two hours after the accident, the incident commander reported that all passengers 

had been evacuated except for one entrapped fatality, even though he could not reconcile the 

greeter list and the passenger list, which indicated the location of passengers by car and room. 

This accident case illustrates the need and interest of first responders for an accurate passenger 

count both to bring an appropriate level of resources to the accident scene and to determine when 

 

50A greeter list shows the names of all those who made a reservation to travel on that train on that day. 

When the passengers arrive to board the train, they check in with an Amtrak employee who greets them 

and checks off their names. It is not uncommon for someone to make a reservation for a particular day and 

then not show up. 
43

search and rescue efforts can be suspended. The absence of such an accurate list, however, 

seems not to have affected accident consequences for the passengers and crew. 

(2) Railroad Accident Brief: Derailment of Amtrak Train No. 5-17 on Burlington Northern and 

Santa Fe Railway Track near Nodaway, Iowa, March 17, 2001

The NTSB accident brief does not provide enough information on the nature of the accident, the 

emergency response, or the victim’s cause of death to allow one to determine whether or not an 

accurate manifest would have resulted in saving the victim’s life. The accident brief does not 

explicitly call out the lack of a manifest as an issue. This was corroborated during an interview 

with the incident commander, who indicated that passenger counts matched Amtrak’s numbers.51 

The victim was an elderly passenger who apparently died as a result of injuries sustained when 

tossed around within the car as it derailed and overturned. 

(3) Collision of National Railroad Passenger Corporation (Amtrak) Train 59 with a Loaded 

Truck-Semitrailer Combination at a Highway/Rail Grade Crossing in Bourbonnais, Illinois, 

March 15, 1999 

About 9:47 p.m. on March 15, 1999, Amtrak train 59 struck and destroyed the loaded trailer of a 

tractor-semitrailer combination that was traversing a grade crossing in Bourbonnais, Illinois. 

Both locomotives and 11 of the 14 cars in the Amtrak consist derailed. One of the cars rolled 

over onto its side. Another car, although upright, was bent around the back of a locomotive, and 

portions of the car were engulfed by fire from spilt fuel.

When the first Bourbonnais Fire Protection District personnel arrived at the accident scene, they 

found that some 30 to 35 employees of Birmingham Steel, a nearby facility, had already 

responded to the accident and had begun the rescue effort. These steel plant employees had cut a 

hole in the chain-link fence separating the wreckage site from the steel plant’s property and had 

brought a number of handheld fire extinguishers and ladders from the plant to combat the flames. 

While some of the steel plant employees applied the fire extinguishers to the flames, others 

entered some of the damaged passenger cars to extricate entrapped passengers. These efforts 

were continued for about 45 minutes until Bourbonnais Fire Protection District personnel, who 

continued the extrication efforts, relieved the steel plant employees. 

The first police units arrived on scene within 3 minutes and began helping to evacuate the 

passenger cars. Within a short time, additional police units responded and officers began 

evacuating passengers wherever they could. The Bourbonnais Police Department established an 

initial staging area on the unpaved roadway on the west side of the tracks, in the area adjacent to 

the wreckage pileup. The evacuated passengers and train crew assembled in this area, where 

responding ambulances later arrived. The first ambulances arrived at the scene within 6 minutes 

and the first fire units within 12 minutes. A fire department field command post was established 

at the initial staging area. 

 

51Telephone conversation with Brian Kannas, Adams County Emergency Management Coordinator, May 6, 2004. 
44

In interviews with the NTSB, emergency responders indicated that the immediate focus of the 

response was the extrication of the trapped and injured passengers and train crew. Because the 

derailed train cars blocked McKnight Road at the grade crossing, three separate staging areas 

were established. Upon evacuation, displaced passengers and train crew were taken to one of 

two triage areas initially established at the scene. Because the temperature that night was 

estimated to be in the low 20s, the incident commander became concerned about the threat of 

hypothermia since most of the evacuees lacked warm clothing. A local retail store offered its 

facility as a temporary shelter, and starting at approximately 10:28 p.m., responders used this 

third facility both as a shelter and as a triage site for several persons who were later found to 

have sustained injuries. 

At approximately 12:05 a.m. on March 16, an emergency shelter established at a nearby school 

building began to receive the uninjured displaced passengers who were transferred from the 

temporary shelter established earlier at the retail store. 

About 50 minutes after the accident, a medical trauma team consisting of physicians and medical 

equipment from local hospitals arrived at the scene. A Braidwood Fire Department officer, who 

arrived about 50 minutes after the first emergency responder, was familiar with petrochemical 

fires and recognized almost immediately that a large amount of foam was necessary to combat 

the blaze. Upon receiving concurrence from the incident commander, he called for heavy foam 

tanker trucks to come from a local chemical plant. The foam tanker arrived and was set up about 

1 hour later; within a few minutes this equipment began to apply foam, and the fire was 

extinguished. Before the arrival of the Braidwood officer, the incident commander had directed 

firefighting operations that had proved ineffective at either extinguishing the flames or at 

keeping the fire away from the sleeper car in which occupants were entrapped. 

Relatively early during the response, emergency responders telephoned Amtrak’s Consolidated 

National Operations Center (CNOC) in Wilmington, Delaware, to learn how many passengers 

rescuers could expect to find. At this time, Amtrak responded that the train could be carrying as 

many as 400 passengers. When Amtrak management arrived on scene, however, they 

determined from the contents of the conductor’s ticket pouch that the passenger count was 196; 

this passenger tally was not considered firm on the following morning. Several days after the 

accident, Amtrak identified the number of confirmed passengers to be 198. However, it was 

several more days before Amtrak developed a complete list of passenger names, and its accuracy 

remained in question. It was only later, when investigators were able to compare that list with a 

list provided by the Illinois State Police, that the correct passenger count of 207 was determined. 

NTSB was not able to definitively establish how many individuals were in the sleeping car at the 

time of the collision, nor could it determine the precise whereabouts of those who were in the 

car. The degree of injury sustained by the car’s occupants ranged from minimal or none, up to 

fatal. Rescuers reported that they were unable to immediately extricate some of the individuals 

they believed to be entrapped within the wreckage. 

Eleven train passengers, all of who were located in sleeper car 32035, the car bent around the 

back of the locomotive, sustained fatal injuries. The fatally injured occupants were in the 

portions of the car at the vertex of the car’s bend, where the crush and intrusion were at a 
45

maximum. This portion of the car was also later consumed by fire. The coroner tentatively 

attributed deaths of 5 of the 11 fatally injured occupants to the effects of the fire. The coroner 

was unable to determine whether any of these five might have succumbed to their traumatic 

injuries had they not been exposed to the fire. The other six fatalities apparently resulted from 

traumatic injuries. 

Because of insufficient training in responding to railroad emergencies or 

inadequate/inappropriate resources, or both, the emergency responders were not prepared to 

respond effectively to a passenger train accident involving a significant diesel fuel fire. 

Six of the passengers apparently died as a result of the crash, before the outbreak of the fire. The 

other five passengers died as a result of the fire that was not brought under control until nearly 2 

hours after the accident. The establishment of three separate outdoor staging areas, followed by 

the establishment of a temporary indoor shelter, and then a second emergency shelter 

complicated the task of completing an accurate census of the injured and uninjured passengers in 

a timely fashion. At that point, even if an accurate manifest were available, knowing that 11 

passengers were unaccounted for and in the burning sleeping car would not have resulted in their 

survival. 

This accident case illustrates the difficulty and time lag in developing a list of rescued passengers 

that could be compared to an accurate manifest to determine the number of missing persons. In 

this case, such knowledge would have had no effect on search and rescue efforts or passenger 

survival or degree of injury. 

(4) Railroad Accident Report: Derailment of Amtrak Train 4, Southwest Chief, on the 

Burlington Northern Santa Fe Railway near Kingman, Arizona, August 9, 1997 

About 5:56 a.m. on August 9, 1997, Amtrak Train 4, the Southwest Chief, derailed about 5 miles 

northeast of Kingman, Arizona. The train was traveling at about 89 mph on the eastbound track 

when both the engineer and assistant engineer saw a hump in the track as they approached bridge 

504.1S. They stated that they applied the train’s emergency brakes. It was later discovered that 

the ground under the bridge supporting structure had washed away during a flash flood. As the 

train passed over bridge 504.1S, the first three locomotive units uncoupled and separated from 

the rest of the train and each other; each unit coming to a stop east of the derailed train. The 

fourth unit remained coupled to the train. The third and fourth units, and all but the last car, 

derailed in the upright position. Although some cars were at a slight angle to each other and 

leaning, all cars remained coupled and generally aligned with the track. The tenth car, a sleeping 

car, came to rest spanning what had been the track at the location of bridge 504.1S.

While the NTSB reports no fatalities, the FRA casualty and accident databases attribute one 

fatality to this accident. The fatality in the FRA data apparently resulted at a later date from 

injuries incurred during the accident. The victim was not entrapped but apparently injured when 

thrown from his or her seat during the derailment. 

Three police officers were already in the immediate area (searching for people who were 

reportedly stranded because of flash flooding) and were dispatched to the scene and arrived 
46

within 10 minutes of the accident. They reported that no life threatening injuries were noted. 

They helped the Kingman Fire Department and emergency services personnel transport 

passengers and crew to triage areas, searched for train occupants, and secured the scene. The 

first medical, rescue, and fire units arrived within 20 minutes of the accident. 

According to the conductor and one assistant conductor, at the time of this accident they were in 

the dining car working on tickets. The conductor said that he did not have time to look at the 

manifest because it was in the dormitory car. He also stated that the manifest contained the 

number of passengers in coach sections and a complete list of passengers in the sleeping cars. 

The conductor said that the manifest should have been up-to-date except for tickets taken at 

Kingman. 

During the emergency response to the Kingman accident, the incident commander requested a 

copy of the Train 4 manifest from an Amtrak employee. The conductor told NTSB investigators 

that a passenger manifest was located in the dormitory car, but he did not have time to obtain it 

because he was helping passengers. The chief of onboard services said that he gave a copy of a 

sleeping car manifest to a firefighter. It took several days for Amtrak to provide an accurate 

passenger count of the entire train. 

Given the nature of the accident (no fire or possibility of entrapped passengers exists) and the 

nature of the injuries (none were life threatening at the time), having an accurate accounting of 

all passengers would have had no impact on saving a life. 

According to the NTSB report, “Although no complete manifest was available during the 

emergency response in this instance, the lack of one did not appear to negatively affect the 

efficiency of the emergency response.” 

This accident case also illustrates the potential problems with locating a manifest and providing 

it to appropriate rescue personnel in a timely manner. 

(5) Derailment of Amtrak Train No. 2 on the CSXT Big Bayou Canot Bridge near Mobile, 

Alabama, September 22, 1993 

On September 22, 1993, about 2:45 a.m., barges that were being pushed by the towboat 

MAUVILLA in dense fog, struck and displaced the Big Bayou Canot railroad bridge near 

Mobile, Alabama. About 8 minutes later at 2:53 a.m., Amtrak Train 2, the Sunset Limited, with 

220 persons on board, struck the displaced bridge and derailed. The three locomotive units, the 

baggage and dormitory cars, and two of the six passenger cars fell into the water. The fuel tanks 

on the locomotive units ruptured, and the locomotive units and the baggage and dormitory cars 

caught fire. 

Since most Onboard Service crewmembers were asleep in the dorm-coach and since the train 

attendants were in the cars on the bridge, passengers in the submerged cars had to make 

decisions on their own and evacuate without assistance. According to passengers in the totally 

submerged car (coach 34068), the lower level and front section of the car filled with water in 

seconds, limiting the time passengers in those sections had to evacuate. The center and rear 
47

sections on the upper level remained out of the water for about 10 minutes, and passengers 

evacuated through the open rear door and window exits on the upper level. Passengers inside the 

coach that was partially submerged and sinking (coach 34083) also stated that the lower level 

and rear of the car filled with water in seconds, limiting the evacuation time for passengers in 

those sections. Bridge timbers held the upper level and front of the second car out of the water, 

and passengers in those sections evacuated through the window exits on the upper level in about 

30 minutes. 

The MAUVILLA’s crew, SCOTT PRIDE (another towboat that arrived on scene) personnel, and 

train crewmembers were all instrumental in rescuing people from the water and evacuating 

passengers from the train immediately following the accident. When the towboats and train crew 

had rescued most of the people from the water, the conductor and assistant conductor began 

taking a head count of the passengers and passed out blankets and pillows. After emergency 

responders arrived at the accident site, they began rescue operations, recovery of bodies, triage, 

and firefighting activities. At this point, had an accurate manifest been available, it would have 

been of little use in saving the lives of passengers identified as missing and presumed trapped in 

the submerged cars. 

The first emergency responders did not arrive until an hour after the accident. Autopsy reports 

show that 42 passengers died from asphyxia due to drowning within minutes of the cars entering 

the water. 

This accident case illustrates the inherent complexity of post-accident passenger accounting and 

survivability in immersion accidents. Surviving passengers were initially in several locations 

(two boats and several land points) so developing a count and list to identify missing persons 

could not be done in a time frame that would impact rescue of surviving passengers. 

This case also shows the value of having records of persons on board in a non-train location that 

would be accessible after an accident. Although in this case, ticket records were kept in a nonsubmerged car, retrieval of passenger accounting information in either paper or electronic form 

may be impossible if the source is located in a submerged car. 

(6) Collision and Derailment of Maryland Rail Commuter (MARC) Train 286 and National 

Railroad Passenger Corporation AMTRAK Train 29 near Silver Spring, Maryland, February 16, 

1996 

On Friday, February 16, 1996, at 5:39 p.m., an eastbound Maryland Rail Commuter (MARC) 

train 286 collided with the westbound Amtrak passenger train 29 Capitol Limited. The accident 

occurred during a blowing snowfall at a railroad location, referred to as Georgetown Junction, 

about 1 mile west of Silver Spring, Maryland. The MARC train 286 was a push-pull commuter 

train consisting of a locomotive unit on the rear end, two passenger cars, and a passenger coach 

cab control car in the lead. The engineer was operating the train from the cab control car in the 

push mode at the time of the collision. The left front quadrant of the MARC cab car (the leading 

passenger car) separated and was destroyed as a result of the collision. The fuel tank of the 

Amtrak lead locomotive ruptured on impact, and the diesel fuel ignited. Fire engulfed the rear 
48

superstructure of the locomotive. Fuel also spilled onto the MARC cab car, ignited, and 

destroyed the car. 

Even though the Montgomery County Fire and Rescue Services (MCFRS) personnel responded 

promptly (about 7 minutes after the accident) to the emergency, they could do nothing to save 

any of the accident victims because passenger coach cab control car 7752 was already 

completely engulfed in flames when the first firefighter arrived on scene. 

The first firefighters to the car reported that the car was fully involved in fire and that they did 

not observe any survivors. They made several attempts to enter the car. The fire was 

extinguished within 10 minutes, after which the firefighters were able to enter the car. They 

were later assisted by members of the Montgomery County Police Department (MCPD) in the 

recovery of 11 victims for coordinating the identification and notification process with the 

Maryland medical examiner. All fatalities were on MARC Train 286. Two crewmembers and 

seven passengers died of smoke inhalation, and one crewmember and one passenger died as a 

result of impact injuries. No attempt to account for missing MARC passengers prior to rescue 

attempts appears to have occurred. Even if an accurate manifest had been available, it would 

have been of little use in saving the lives of passengers identified as missing and presumed 

trapped in the burning car. 

Amtrak reported to NTSB investigators that at approximately 6:15 p.m. (about 35 minutes after 

the accident) one of its officers made four attempts within 10 minutes to provide the passenger 

list and other information to the MCFRS personnel at the command center. He was told that the 

information was not needed and that he should wait. 

This accident case illustrates that fire control and rescue are the immediate focus for responders 

and that passenger accounting is less essential and occurs later in the response process (i.e., 

immediate information is not needed or used to guide rescue efforts in a severe accident). 

(7) Collision of Northern Indiana Commuter Transportation District Train 102 with a TractorTrailer Portage, Indiana, June 18,1998

About 4:31 a.m. on Thursday, June 18, 1998, Northern Indiana Commuter Transportation 

District (NICTD) train 102, a 2-car passenger train, collided with the right side of a long 

combination vehicle (LCV) at the Midwest Division of the National Steel Corporation’s grade 

crossing near Portage, Indiana. About 542 feet east of the crossing, the train 102 crew noticed 

the LCV’s second semitrailer, which carried a steel coil weighing about 19 tons, on the crossing. 

The engineer said that he placed the train in emergency braking; followed by the conductor, he 

then exited the control compartment and ran toward the rear of the passenger compartment. The 

crew alerted passengers in that area about the impending collision and told them to evacuate. 

As the collision occurred, the single chain securing the steel coil to the second semitrailer broke. 

The released steel coil entered the lead car of the train through the front bulkhead. The coil 

moved through the car until it came to rest about 34 feet into the passenger compartment. 
49

The emergency response personnel arrived at the accident site within 10 minutes. The uninjured 

passengers and the crew exited through the last door on the south side of the second car. By the 

time they had exited the train, emergency personnel (police) were arriving, and the engineer told 

them where to find the injured passengers. At this time, the incident commander was advised 

that three people were inside the first NICTD car and that two were dead and one was alive, but 

severely injured and pinned under the steel coil. The incident commander immediately requested 

a crane to raise the coil, requested a University of Chicago Aeromedical Network helicopter, and 

contacted a nearby trauma center and advised them to prepare for emergency surgery. While the 

additional help was being sought, a paramedic firefighter tried to communicate with, administer 

oxygen to, and monitor the cardiac status of the severely injured person pinned under the coil. 

Approximately 10 minutes later, the incident commander was told that the injured person had 

lost all vital signs. 

A 19 ton steel coil crushed the victim. Despite timely response by emergency responders, 

despite the fact that all passengers and crew were accounted for, and despite the fact that 

emergency responders were told the exact location of the entrapped victim, he died shortly after 

the arrival of the emergency responders due to the nature of his injuries. An accurate accounting 

of all passengers would have had no impact on saving the victim’s life. 

Conclusions from Examining Fatal Accidents 

Given the sparse data available it is difficult to draw sweeping general conclusions. Based on 

the cases available (including the two involving commuter rail fatalities), however, it seems that 

the availability of a perfectly accurate passenger manifest would not have resulted in a 

passenger’s life being saved or the degree of injury reduced. No examples have been found in 

which promptly accounting for passengers and crew has affected survivability or severity of 

injury. 

However, a good approximate figure (e.g., 75 passengers versus 400 passengers) is needed in 

reporting the accident to give the emergency responders a sense of what they will encounter and 

what resources need to be marshaled. 

Moreover, an accurate manifest is only one part of the solution to the passenger accountability 

problem. Matching known passengers to a list either by means of a simple head count or taking 

attendance (a head count with associated names) as soon as possible after the accident is the 

other necessary part of the solution. In the Amtrak accident at Syracuse, New York, it took 

about an hour for first responders to count 100 passengers. In the Amtrak accident at Nodaway, 

Iowa, it took first responders between 3 and 4 hours to count 241 passengers. Of the accidents 

involving Amtrak trains that occurred between 1993 and 2003 and documented by NTSB, the 

number of Amtrak passengers has varied from 83 (Intercession City, Florida) to 413 (Crescent 

City, Florida). 

An accurate manifest would appear to be of more use in determining when rescue/recovery 

efforts can be declared officially over. Anecdotal information and interviews with first 
50

responders indicates that the emergency responders will complete a search of the wreckage 

before doing this, irrespective of passenger accounting information. 

Finally, an accurate manifest or passenger list must be developed after an accident for the 

notification of next of kin and in processing and determining the validity of potential liability 

claims against the carrier. Both on-site records by first responders and Amtrak passenger 

databases are used for these purposes and checked for consistency. 

6.2 Factors Affecting Passenger Survivability in a Train Accident 

A review of the NTSB reports on Amtrak accidents revealed a number of factors that have an 

impact on a passenger’s survivability after a train accident. Similar considerations from earlier 

Volpe Center work on this subject appear in Appendix E. It is useful to examine the role of 

accurate passenger accounting on survivability from the context of all the factors that influence 

the effectiveness of emergency response teams in assisting accident victims. The factors 

identified in reviewing accident reports affecting survivability and injury severity after a 

passenger train accident include the following: 

Type of accident result–fire, immersion, cars tipped or mangled, or none of the above 

Accidents that result in fire and/or immersion imply the need for immediate evacuation. 

Accidents resulting in cars on their side, otherwise mangled or twisted imply the potential 

for occupant ejection or their being trapped in wreckage. Less severe accidents involving 

none of these consequences allows for a more leisurely assessment of injuries and 

accounting of passengers. The first three types of more severe accidents imply an 

increased chance of fatalities. 

The availability of an accurate manifest would seem to be of no use in the fire and 

immersion cases except for recovery (as opposed to rescue) efforts. The availability of 

an accurate manifest would seem to be of little use in the last (less severe) case since 

accounting for missing persons is not an issue. The availability of an accurate manifest 

could be a factor in the case of tipped or mangled cars depending on the timeliness of the 

emergency response, the extent of extrication efforts required, the time it takes to develop 

an accurate head count of the passengers and crew, and the severity of the passenger 

injuries. 

Type of equipment–sleeper or coach only 

Sleepers complicate search, rescue, and recovery since there are more compartments to 

search and access may be hindered in more severe accidents. The presence of sleepers 

can increase the chance of fatalities and injury severity if it delays rescue efforts. 
51

Time of day 

Darkness hampers evacuation and rescue efforts, especially with a lack of adequate 

emergency lighting both inside and outside of cars. Darkness results in an increased 

chance of fatalities. 

Training of crew 

Has the crew received recent training in emergency procedures? Have the passengers 

been given the opportunity to become familiar with emergency procedures? Up-to-date 

crew training in emergency response and passenger familiarization with emergency 

procedures and location of emergency exits result in a decreased chance of fatalities. 

Crew incapacitated 

The crewmembers are often the first emergency responders. If the crew is not available, 

the passengers are on their own until outside help arrives. The lack of a functioning crew 

results in an increased chance of fatalities. This possibility also suggests the need to have 

a copy of the manifest at an off-the-train location in case the onboard copy is inaccessible 

and/or the crewmember responsible for the manifest is incapacitated. 

Bystanders/good Samaritans involved 

If available, good Samaritans would most likely be the second emergency responders, 

after the crew. The good news-bad news is that while they may save lives, they are not 

likely to be organized and may complicate the problem of accounting for all passengers. 

Their presence implies a decreased chance of fatalities, since in an emergency situation 

the standard operating procedure (at least in the first three types of accidents noted above) 

is to evacuate/rescue everyone who can be located as soon as possible and then worry 

about the issue of accounting for missing passengers. 

Timeliness of emergency response 

This is affected by location (urban/rural), accessibility, and communications (accurate 

reporting of accident location in terms responders can understand). Increased response 

time, for whatever reason, results in an increased chance of fatalities. 

Training of emergency responders 

Have emergency responders received training in dealing with a passenger rail accident? 

Specialized training in responding to a rail accident results in a decreased chance of 

fatalities. 
52

Number of passengers and crew 

Counting heads or taking attendance takes time, resources, and organization; the time 

required increases with the number of passengers involved and accident severity. The 

knowledge that all passengers are not accounted for does little to increase their chances of 

survival if it takes an excessive amount of time to make that determination. An 

established, controlled staging and triage area is as important as an accurate manifest in 

accounting for passengers, and well-trained and organized first responders routinely 

attempt to keep records on those rescued. The greater the number of passengers and the 

more diffuse the accident and recovery area, the greater the amount of time needed to 

compare information and determine whether anyone is missing, and the more likely that 

life-threatening injuries will prove fatal or more debilitating. 

It can be concluded that factors other than a reliable and accurate passenger accounting system 

generally determine a passenger’s survivability. 

6.3 Emergency Responders’ Perspective on the Value of an Accurate Manifest 

A key issue in this study is to determine how an accurate manifest would make the emergency 

responders’ efforts more successful and the likelihood that it would be effective in typical 

accident situations. To address this issue, Amtrak safety and other emergency (first) responder 

organizations were contacted in an attempt to document both the typical or ideal case and the 

real-world complexities sometimes encountered. 

Results of interviews with emergency responders are consistent with the conclusions of the 

limited value of an accurate manifest noted in the previous section.52

All of the responders interviewed recognized the value of good information. Ideally, they would 

like to know the order of magnitude of the problem in terms of the number of passengers and 

number of injuries before arriving on scene. This allows them to arrange for the required 

resources (e.g., ambulances, alternative transportation for uninjured passengers, and emergency 

shelters) as expeditiously as possible. If they did not have that information before arriving on 

scene, they would try to locate the train crew or contact Amtrak to obtain the information. 

Otherwise, the first responder to the accident would call for required backup after assessing the 

situation and assuming the worst in determining the need for additional resources. 

In the Nodaway, Iowa derailment, the first call the emergency responders received indicated that 

there had been a train accident. Only in a subsequent call were they told that it was an Amtrak 

accident. They then had to request backup (from as far as 70 miles away) because of the 

possibility of a large number of injuries. They did not learn the number of passengers on the 

train until they arrived on scene and were given this information by the conductor. The 

 

52Telephone conversation with Brian Kannas, Adams County Emergency Management Coordinator, 

May 6, 2004; telephone conversation with Joe Rienfrerd, Onondaga Director of Fire, May 5, 2004; telephone 

conversation with Pat Sullivan, Chief, Gulfport, Mississippi Fire Department, May 5, 2004. 
53

conductor first checked on the status of the crew, and then directed the crew to check on the 

status of each car, with individual crewmembers assigned to specific cars. He reported the 

location and number of injured to the first responders. The incident commander ordered school 

buses to transport the uninjured to shelters and ambulances to transport the injured to hospitals. 

He also had medivac helicopters from Omaha and Des Moines available, as well as a police 

helicopter with a heat detection camera to search for people if needed.53

One responder noted that his approach was to first do a hasty initial search, find all passengers, 

comfort passengers, and get their names. This hasty search would be only the first of multiple 

searches. The responder felt that an accurate list was invaluable so that they could match it to 

people in the field. He also noted that names would be important in notifying loved ones. He 

would try to match names to the passenger list if it were available. He felt that knowing the 

number of passengers in each car was important since he would have teams assigned to search 

individual cars to speed up the process of accounting for passengers. He also recognized the 

need to cordon off the area, and to control the scene so that people did not wander off or be taken 

away by bystanders.54

Another responder was involved with the Amtrak collision accident near Syracuse, New York, in 

2001. Their approach to any hazardous situation is to save lives first. This applies to a rail 

accident. First they locate and evacuate passengers, then obtain a count, and finally look for 

missing people, if any. 

In this case, the engineer gave the emergency responders the number of passengers on the train. 

The incident commander then called for buses to transport the uninjured, provided for shelter, 

and established triage. Their approach was to round all the people up, put up barrier tape, and 

keep them penned in. One of the first things responders do is get names. This is done in triage. 

All passengers are evaluated in triage whether hurt or not. Part of the triage process is to create a 

pre-hospital care report (PCR) for each individual. The emergency medical technician (EMT) 

completes this medical evaluation form. Passengers were sent to a transfer area were buses were 

provided for the uninjured and ambulances for the injured. 

They developed an initial name list from the PCRs and did a double check. In this case it took 

about an hour to get a count of 100 passengers. The responder noted that the time required to get 

a count would vary with the number of passengers. 

Ideally, the emergency responders would like a passenger list to check against their list of treated 

passengers to determine if they have everybody. It took several hours to get a list from Amtrak, 

and all passengers had been transported from the scene when the list arrived. 

 

53Telephone conversation with Brian Kannas, Adams County Emergency Management Coordinator, 

 May 6, 2004. 

54Telephone conversation with Pat Sullivan, Chief, Gulfport, Mississippi Fire Department, May 5, 2004. 
54

People can be thrown some distance from the train cars. The emergency responders did not 

suspend rescue and recovery efforts until after searching all cars and the nearby area. A big red 

X was painted on each car to show that it had been searched and that it was empty. 

According to this first responder the value of an accurate manifest is in obtaining closure, in 

knowing absolutely that you have everybody, and that you did not leave someone behind.55

In the Nodaway, Iowa, derailment no problem occurred in evacuating passengers from cars. 

They were first sent to a staging area, then to buses or ambulances. The responders did not 

collect names at this point but only did a count of those put on buses and the number sent in 

ambulances. They did not have a name list from Amtrak. Names were taken at the shelter and 

hospitals. 

The emergency responders relied on a head count and a search of the area surrounding the 

accident. The number of passengers was never an issue, since their counts matched Amtrak’s 

numbers. The head count took 3-4 hours. There were 241 passengers in this case. They counted 

people as they left the scene and counted them again at the shelters and hospitals. 

After all cars were evacuated, a second search of each car was conducted, and an X was spray 

painted on each car when the search was completed to indicate that the car was all clear. This 

second search is standard procedure (i.e., is done irrespective of passenger accounting 

information). 

If it was believed someone was missing, they would have used the police helicopter to search the 

area. They would do whatever it took to find the missing persons and would search until they 

were found. At this point, names would be important because the responders would start 

matching names collected at hospitals and shelters to those on Amtrak’s passenger list to 

determine if a person was in fact missing and who they were.56

Two of the responders mentioned another value of an accurate manifest not identified in the 

previous discussion, namely, security. The tracking issue was becoming increasingly important 

on all public transportation modes (rail, bus, etc.), implying not only a need to know that a 

person was unaccounted for, but also who that person was in order to attempt to determine if the 

missing person might be a terrorist.57

Amtrak’s Director of Emergency Preparedness recognized the problem inherent in comparing 

the passenger count from the electronic manifest with that of the ticket pouch. He saw the value 

of an accurate manifest as assuring the responders that no one was left behind. He also noted 

that the responders exercise extreme diligence to avoid leaving anybody behind. He had never 

 

55Telephone conversation with Joe Rienfrerd, Onondaga Director of Fire, May 5, 2004. 

56Telephone conversation with Brian Kannas, Adams County Emergency Management Coordinator, 

 May 6, 2004. 

57Telephone conversation with Joe Rienfrerd, Onondaga Director of Fire, May 5, 2004; telephone conversation with 

Pat Sullivan, Chief, Gulfport, Mississippi Fire Department, May 5, 2004. 
55

heard of a specific case of a person being unaccounted for and discovered later. While he felt 

that the emergency responders were usually effective in preventing people from leaving the 

accident scene before being identified, he thinks that it probably has happened.58

6.4 Hypothetical Scenario in Which Survivability is Affected by Passenger Accounting 

A hypothetical accident scenario in which a manifest might matter in saving lives would include 

the following elements: 

The accident involved a serious derailment with cars on their sides, some seriously 

injured passengers trapped in the wreckage, and the absence of fires or other continuing 

hazardous conditions. 

The crew survives, has an accurate passenger list, takes attendance quickly (e.g., in less 

than 10-15 minutes), and determines that one or more passengers are missing in the 

wreckage and their likely location. 

Emergency responders arrive on scene quickly (e.g., in less than 10-15 minutes) with 

equipment needed for extrication efforts. 

The injuries are severe and the entrapped passengers will only survive if quickly found, 

treated, and delivered to a hospital, but they will die if not quickly found and tended to. 

Emergency responders can locate and extricate the severely injured victims and get them 

to a hospital within the window of opportunity. 

Several of these circumstances are improbable. That they would occur in combination such that 

one or more lives would be saved is extremely unlikely and this would seem to explain at least 

partly why no such case was found in reviewing recent accidents. 

6.5 Conclusions about the Value of an Accurate System for Accounting for Persons on 

Board Amtrak Trains 

When serious Amtrak accidents occur, having a count of the number of persons on board has 

three main uses. First, if an estimate is provided as part of the accident reporting process first 

responders will be able to better gauge the need for resources. Second, as the search and rescue 

process proceeds, an accurate list to compare with persons evacuated can be used to determine 

whether there may be missing persons or that all persons are accounted for. Third, a list 

containing names and other personal information will also be of subsequent use to Amtrak for 

purposes, such as notifying next of kin and in dealing with legal liability matters. 

The NTSB recommendation that an accurate accounting system be developed and implemented 

implicitly assumes it would have a meaningful safety benefit. It is thus necessary to assess the 

value of such a system in terms that can be compared to the costs of implementation. Each of the 

 

58Telephone conversation with Larry Beard, Senior Director of Emergency Preparedness for Amtrak, May 13, 2004. 
56

identified uses are examined below to determine its affect on safety and indicate a measure of the 

likely impacts. 

Gauging Resources Required for an Accident Response

To gauge the amount of resources to dispatch to a rail accident, responders need information 

about the type and size of the accident and the number of casualties requiring emergency medical 

care and transportation. Amtrak crews are trained to quickly assess the situation and include this 

information in reporting the accident. Reporting the number of persons on board is a very 

indirect way to provide some indication of the possible number of casualties and perfect 

accuracy is not required for this purpose. In spite of their imperfections, Amtrak’s current 

reservation, manifest, and ticket pouch systems are satisfactory sources for approximate counts 

of persons on board, especially if existing guidelines for their use are followed. Timely 

knowledge of the number of casualties and their severity, rather than an accurate count of 

persons on board, could expedite treatment and have potential life-saving implications. 

Indicating the Possibility of Missing Persons

Emergency response teams are trained to perform systematic searches of accident and disaster 

sites to locate all victims. Part of this standard practice is to count rescued persons and collect 

personal information about these individuals. Comparing this on-site accident response 

information to records of persons on board takes time and is not the first priority of emergency 

responders. Even if the two counts are consistent, prudent practice dictates that names be 

matched, and this is a cumbersome process in the post-accident emergency response 

environment. Even if both lists are perfectly accurate, the combination of circumstances that 

would lead to finding additional persons quickly enough to affect their survivability is 

improbable. No such cases are known to have occurred, and, in recent cases with detailed 

published accident reports, the rescue of surviving passengers were completed before the time 

that missing person data could be assimilated and analyzed. 

Emergency responders will normally perform careful searches irrespective of any indication of 

missing persons. Inaccurate records of persons on board might cause some continuation of 

search and rescue operations that might otherwise have ceased, but only if the error was to list 

more persons than were actually on board. It is more likely that imperfections in Amtrak’s 

passenger accounting system would result in undercounts rather than overcounts of persons on 

board and thus would not cause unnecessary searches. The extra costs of extending the search 

period could be extra pay, but might be performed within regularly scheduled duty time. Any 

extra search costs would likely be so small and infrequent as to be ignored in any cost-benefit 

analysis, and in any event do not have direct safety implications. 

Providing Information for Post-Accident Notification and Records

As a common carrier, Amtrak has post-accident responsibilities that require information as to 

persons on board. Pre-accident data will always be compared, verified, and supplemented by 

information collected during the emergency response. Accurate pre-accident information would 
57

facilitate this process, but has no safety benefit nor notable cost saving other than potentially 

reducing fraudulent liability claims. 

59

7. Alternative System Concepts for Improved Passenger Accounting: 

Description and Evaluation 

7.1 Introduction 

A key objective of an improved passenger accountability system is to provide an accurate listing 

of persons on board, including limited personal information to be used as part of an emergency 

response (i.e., name, and perhaps age or age category, gender, and contact person/number). If 

NTSB is to be taken literally, the new system will have to provide information on the exact 

number and identity of passengers on board at all times. 

The proposed system improvements do not include linkages to security databases or passenger 

screening. However, it seemed prudent to anticipate Transportation Security Administration 

(TSA) concerns and suggest system options that include the capability of indicating who is on 

the train at all times. 

To evaluate the feasibility of system improvement options, Volpe Center staff estimated their 

development, capital, and operating costs. It is likely that an interface with Amtrak’s existing 

reservation system will need to be developed, though an upgrade or replacement would likely be 

considered early in any implementation planning effort. The other system elements would likely 

be off-the-shelf hardware. 

The estimated costs indicated in this study should be viewed as order of magnitude estimates. A 

more detailed level of analysis would be required to develop more precise estimates based on a 

comprehensive list of components, quantities, unit costs, and the cost of operating the current 

baseline system. 

This feasibility assessment identifies the advantages and disadvantages of the options considered 

in qualitative terms. Systems are defined on the basis of the components needed. Benefits are 

discussed in qualitative terms but not quantified in terms of dollars or other measures. 

Concept descriptions for six options are considered. These include the current system, assuming 

the ideal operating case, followed by five other options that range from simple changes to the 

existing system to options involving significant changes in Amtrak operating policies as well as 

significant changes in technology. The latter four alternatives involve some degree of 

automation of the ticket collection process and the use of some type of machine readable ticket. 

The alternatives considered include the following: 

• Base Case 

Amtrak’s current passenger accountability system based on Arrow CRS and the 

conductor’s ticket pouch. Tickets are collected on board. Tickets are not required to 

board a reserved train. 
60

• Improved Onboard Paper-Based System 

Allows onboard collection (sale) of paper tickets with improved paper accounting of 

passengers. Updated passenger reservation system information is manually 

transferred to the train at stops with staffed stations. Information about passengers 

not previously captured by the reservation system, for the just-completed route 

segment, is manually transferred at stops with staffed stations. 

• Automated Onboard Ticket Collection System 

Allows onboard collection (sale) of machine-readable tickets. Updated passenger 

reservation system information is electronically transferred to the train at station 

stops. Updated passenger (ticket lift) information for the just-completed route 

segment is electronically transferred to the reservation system at station stops. 

• Automated Onboard Ticket Collection System with Improved Information Transfer 

Allows onboard collection (sale) of machine-readable tickets. Updated reservation 

system information is electronically transferred to the (moving) train prior to the 

ticket lift, and passenger (ticket lift) information is electronically transferred from the 

(moving) train upon completion of the ticket lift. 

• Electronic Tickets with Platform Gate Readers and Car Door Readers 

Electronic verification of smart card-based tickets on entry to and exit from the train 

or station platform (at major stations only). Tickets are required for boarding (i.e., no 

onboard sales). Updated passenger list information is electronically transferred at 

each station stop before train departure. 

• Electronic Tickets with Car Door Readers 

Electronic verification of smart card-based tickets on entry to and exit from the train. 

Tickets are required for boarding (i.e., no onboard ticket sales). Updated passenger 

list information is electronically transferred at each station stop before train departure. 

The remainder of this section includes the following: 

• Describes the current and proposed alternative passenger accountability systems in terms 

of their general functionality, advantages, disadvantages, and order-of-magnitude cost 

estimates. 

• Provides information on the sources and derivation of the unit costs and quantities used 

in deriving the cost estimates. 

• Presents a qualitative discussion of the potential benefits of an improved passenger 

accountability system. 

• Offers some conclusions and recommendations based on a consideration of the 

characteristics of the alternative passenger accountability systems. 
61

7.2 Alternatives for Improved Passenger Accounting 

Order-of-magnitude costs for a number of alternative passenger accountability systems were 

estimated. Both one time and annual ongoing (operating) costs were estimated. These systems 

represent a spectrum of alternatives starting with the current system, the Base Case, and moving 

toward alternatives that would require increasing changes in Amtrak’s current way of doing 

business. 

Only two of the proposed options meet NTSB requirements for a passenger accountability 

system. The others are straw men to illustrate the point that changes to the existing system will 

likely involve increased costs while not meeting requirements or providing any significant 

benefits. Table 7 summarizes the characteristics of the alternatives and the following subsections 

describe them in more detail. Appendix H describes unit costs and quantities that form the basis 

of the estimates. 

Cost estimates for the alternatives do not include costs associated with integration with Amtrak’s 

Arrow CRS or an upgrade or replacement of Arrow. Cost changes associated with conductors, 

ticket agents, or ticket offices were also not estimated. Costs associated with processing cash 

revenues were not estimated. These three costs would be common to all four automated 

(electronic) alternatives. For four of the alternatives considered, revenue accounting could be 

done electronically, essentially in real time. This is a potential benefit of an automated 

ticketing/fare collection system. However, the potential savings due to the conversion of the 

revenue accounting process from a paper-based to an electronic system were not estimated. 

These estimates were made assuming that future ridership and revenues levels were the same as 

the historic 2003 level. 
62

Table 7. Characteristics of the Alternative Passenger Accountability Systems 

Alternative Ticket 

Collected 

Ticket Lift 

Information 

Processed 

Manifest 

Updated 

Sales/Reservations/ 

Collections Reconciled 

in Near Real Time 

Information 

Transfer 

Train/CNOC 

Base Case On board In Revenue 

Processing 

At CNOC No Partial Transfer at 

Select Staffed Stations 

Improved Onboard Paper-Based System 

On board In Revenue 

Processing

At CNOC No At All Staffed 

Stations

Automated Onboard Ticket Collection System 

On board On board On board Yes At All Stations 

Automated Onboard Ticket Collection System with Improved Information Transfer 

On board On board On board Yes At Completion of 

the Ticket Lift 

Electronic Tickets with Platform Gate Readers and Car Door Readers 

At gate/at car door 

At gate/at car door

At gate/at car door

Yes At All Stations 

Prior to Train Departure

Electronic Tickets with Car Door Readers 

At car door At car door At car door Yes At All Stations 

Prior to Train Departure

CNOC is Amtrak’s Consolidated National Operations Center 
63

Table 7. Characteristics of the Alternative Passenger Accountability Systems (continue

Alternative Timeliness of 

Updates 

Consistency Onboard List 

/CNOC List 

Always 

Accurate 

Provides Numb

Onboard 

Base Case Meaningless No No Yes Improved Onboard PaperBased System Always one staffed station behind No No Yes Automated Onboard Ticket Collection System 

Time lag due to ticket lift and data transfer 

No No Yes 

Automated Onboard Ticket Collection System with Improved Information Transfer 

Time lag due to ticket lift 

No No Yes 

Electronic Tickets with Platform Gate Readers and Car Door Readers 

Always current Yes Yes Yes 

Electronic Tickets with Car Door Readers 

Always current Yes Yes Yes 

CNOC is Amtrak’s Consolidated National Operations Center.
64

7.2.1 Base Case 

System Description 

Passenger accountability on reserved trains is part of the larger Amtrak system for reservations, 

ticket sales, ticket collection, and revenue accounting. A major factor complicating passenger 

accountability is the nature of travel on intercity trains, that is, with multiple intermediate stops 

and long trip duration. Moreover, under current policies and practices it is possible to get on an 

Amtrak reserved train without a ticket and without a reservation. Thus, a verified list of 

passengers on board is not available at the time of a train’s departure from its station of origin. 

Amtrak’s current passenger accountability system includes three elements: the conductor’s ticket 

pouch, the printed onboard manifest, and the Arrow system’s database. Under the current 

system there are no, or at best inadequate, real time links between these three elements to 

reconcile reservations made, tickets issued, and tickets used. At any point in time a count of the 

number of passengers on board will be different in each of the three elements. Formal counting 

of tickets used, which provides a historical record of the number of passengers that were on the 

train, is not completed until the conductor’s pouch is put through the revenue accounting process 

sometime after completion of the train run. 

Procedures are in place to handle various unusual events, such as stopovers, carry-bys, and 

passengers leaving the train before their scheduled stop. These procedures are geared toward 

keeping the conductor’s ticket pouch up-to-date and to reflect an accurate picture of what 

happened on the train for revenue accounting. However, no provisions are in place to update the 

Arrow manifest to reflect these circumstances, and even the updated information in the ticket 

pouch can be incorrect because of various weaknesses in the system. 

Ticketed passengers are included in the Arrow manifest. However, no provision exists for 

accounting for no-shows until the passenger applies for a refund. Unticketed passengers (those 

who have not physically picked up their ticket prior to boarding) also appear on the Arrow 

manifest. The onboard manifest is printed 30 minutes before departure from the station of origin 

and 30 minutes before departure from intermediate crew change points. Reservations and ticket 

sales made after the predeparture window do not appear on the printed onboard manifest. 

Tickets collected are added to the ticket pouch upon completion of the ticket lift after departure 

from each station. Onboard sales receipts for tickets issued to unticketed revenue passengers are 

also added to the ticket pouch. Ideally, the conductor completes a Form 3085 in addition to the 

onboard sales receipt, add this to the ticket pouch, and drop a copy at the next open staffed 

station to update the Arrow manifest and the onboard manifest created at crew change points. 

Amtrak multi-ride ticket options (and commuter railroad passes59) are sold outside the context of 

the reservation system by phone, mail, ticket counter, or ticket machine. Passengers using these 

passes are accounted for in the ticket pouch and revenue accounting by the “Record of Tickets 

 

59 MARC passes are honored on a Reserved Regional and Unreserved Regionals. Virginia Railway Express passes 

are honored on the Carolinean, Crescent, Cardinal, Reserved Regionals, and Unreserved Regionals. Shore Line East 

passes are honored on Reserved Regionals, an Unreserved Regional, and an Acela Express. NJ Transit passes are 

only honored on unreserved trains. Metrolink passes are only honored on unreserved trains. 
65

Honored but not Lifted.” They are not accounted for in the printed onboard manifest or in the 

Arrow manifest. 

Non-revenue passengers may have a ticket reflecting either a reduced fare or no fare and would 

be treated like any other ticketed passenger. Non-revenue passengers not holding a ticket enter 

into the manifest updates by way of Form 3085. This requires the conductor to complete a Form 

3085, to drop off the Form 3085s at the first staffed station, and station personnel to enter the 

data into Arrow. The conductor can obtain an updated manifest by departing the train and 

logging onto Arrow, though this does not regularly occur. Non-revenue passengers are 

accounted for in the ticket pouch and revenue accounting by either a Form 3085 or a ticket. 

Advantages/Disadvantages of Base Case 

Amtrak’s passenger accountability system does not meet NTSB’s requirement for knowing the 

number and identity of passengers on reserved trains at all times. Three inherent defects exist in 

the current set of procedures for passenger accountability. 

The first is the difference between actual practice as opposed to the official policy outlined in the 

Service Standards Manual. It is not clear how rigorously the procedures outlined in the Service 

Standards Manual in regard to Form 3085s are followed in practice. Perfect compliance would 

assume that conductors issued a Form 3085 for all passengers not having an Arrow ticket and 

appearing on the Arrow manifest, and they would then drop the Form 3085s at the first open 

staffed station that would not result in delaying the train. 

However, even with perfect compliance with the official policy, defects exist in the policy itself 

which preclude its being a satisfactory solution to meeting the NTSB requirements. First, the 

policy of dropping off Form 3085s at the next open staffed station results in significant gaps in 

time in which this information is not available to Arrow. In some cases this information will not 

be available to Arrow until after the train has completed its run. Another problem associated 

with the timeliness of information is due to the use of the ticket lift. Collecting tickets after the 

train leaves the station creates a time gap in which the number of passengers on board is 

unknown, even if the results of the lift could be transmitted off the train immediately upon 

completion of the lift. 

The final defect is that because of the implicit assumption that passengers will in fact always 

depart the train at the station indicated on their ticket. Not accounting for passengers leaving the 

train leads to potential discrepancies in the actual number of passengers on board as opposed to a 

list of passengers who should be on board according to the origin-destination indicated on their 

ticket. 

Form 3085s are not issued in case of individuals who have missed their stop and are returning to 

their intended destination, or to commuter rail passholders or Amtrak multiride passholders who 

are legitimately or illegitimately riding a reserved Amtrak train. In addition, no procedures are 

in place to communicate to Arrow the fact that an individual who has missed his or her stop is 

still on the train, or that individuals have left the train before the stop indicated on their ticket 

either because of a stopover, illness, injury, disruptive behavior, or other personal reasons. If the 
66

conductors have completed all the specified forms, these individuals would be accounted for 

after the fact in the revenue accounting process. However, individuals who left the train without 

first informing the conductor are not accounted for. 

7.2.2 Improved Onboard Paper-Based System 

System Description 

This alternative would be the same as the current Amtrak passenger accountability system with 

the following changes. First, conductors would have a complete list of passenger names for 

check off as part of the ticket lift process. They would be required to complete a Form 3085 for 

all passengers not holding an Arrow ticket without exception, including all passholders and all 

individuals traveling in families and multi person parties who purchase tickets on board, and 

create negative 3085s for no-shows. Conductors would be required to drop off Form 3085 

updates at all staffed stations without exception, but the conductor would not be required to leave 

the platform. Instead, station staff would be required to meet the conductor on the platform to 

collect the Form 3085s and provide the conductor with the latest version of the Arrow manifest.

Advantages/Disadvantages of Improved Onboard Paper-Based System 

This case takes a step toward ensuring that actual practice follows the policy on Form 3085 

updates outlined in the Service Standards Manual and makes the stated policy more meaningful 

in requiring Form 3085 drop-offs at all staffed stations. While this system addresses some of the 

problems in the current system related to actual practice versus stated policy, it does not address 

inherent defects in the current system. 

It has advantages over the current system because it provides name information for all 

passengers including pass holders and onboard sales, and accounts for passholders and onboard 

sales in the manifest update. At staffed station stops, it accounts for no-shows, eliminates the 

need for the conductor to verify reservations for unticketed passengers over a phone, and ensures 

that the manifest is updated at each station stop. 

This approach does not meet NTSB requirements. It would not capture people leaving before 

their scheduled stop or those missed by the conductor in the ticket lift. Timeliness of information 

would still be a problem as under the current system, since the information about passengers 

surrendering or purchasing a ticket on board that is available through the Arrow CRS at CNOC 

will always be one station behind.

Costs of Improved Onboard Paper-Based System 

Additional conductor workload may require increasing the number of conductors on select trains. 

Depending on current station staff levels and work loads, additional station staff or staff hours 

would be needed to accommodate the new job function of collecting Form 3085 updates from 

the conductor on the platform and immediately entering the data into Arrow. 
67

In addition, a mobile, system-wide, auditing department would be required to ensure near perfect 

compliance with a requirement for conductors to complete a Form 3085 for all passengers not 

holding an Arrow ticket. Attempting to reconcile Form 3085s after the fact in revenue 

accounting would not provide an accurate check on conductors. 

Costs associated with these additional requirements would mostly be the subject of detailed 

staffing analyses, probably union negotiations over changed working conditions and 

management decisions, and thus were not estimated. 

7.2.3 Automated Onboard Ticket Collection System 

System Description 

Under this alternative the conductor would use a handheld device to scan tickets and passes, and 

issue tickets. All revenue and non-revenue passengers would have or be issued a ticket or pseudo 

ticket. All tickets and passes issued by ticket machines, ticket offices, travel agents, and on 

board would have a consistent machine readable format. Ticket lift data would be downloaded 

to an onboard computer. This would have to be a hardened and protected computer. Data would 

be transmitted at the next station stop via WIFI60 technology to the station computer and then to 

CNOC where the manifest would be updated. The latest version of the passenger list, including 

the latest list of ticketed and unticketed individuals scheduled to board at the upcoming station, 

would be transmitted to the station computer from CNOC just before the train’s arrival at the 

station and then to the train upon its arrival at the station via WIFI technology. Current practice 

of allowing onboard sales would continue since tickets would not be checked prior to boarding. 

Advantages/Disadvantages of Automated Onboard Ticket Collection System 

This alternative would have an advantage over the current system because it would provide name 

information for all passengers including pass holders and onboard sales, would account for 

passholders and onboard sales in the manifest update, would account for no-shows at each 

station, would eliminate the need for the conductor to verify reservations for unticketed 

passengers over a phone, and would ensure that the manifest was updated at each station stop. 

This system addresses some of the problems in the current system related to actual practice 

versus stated policy but does not address inherent defects in the current system, such as 

timeliness (the one-station-behind problem) of updates to the manifest. Since the list of 

passenger tickets scanned in the ticket lift is not transmitted off the train until the next station 

stop, any list available at CNOC would not include passengers boarding at the current station 

stop, would not be valid for the current route segment, and at best might be valid for the route 

segment just completed. 

 

60 WIFI uses radio frequency transmission to connect computers to each other. WIFI operates in the 2.4 and 5GHz 

radio bands with data transfer rates of 11 Mbps or 54 Mbps providing performance similar to wired Ethernet 

networks. 
68

The manifest produced under this alternative would provide a list of passenger tickets 

scanned/issued by the conductor after completion of the ticket lift, less scheduled departures at 

the given station stop. This may or may not be a list of passengers on the train at that point due 

to potential fare evaders, conductor mistake, or premature departure (a potential security 

concern). 

This approach does not meet NTSB requirements. This system will not capture people leaving 

before their scheduled stop or those missed by the conductor in the ticket lift. Timeliness of 

information would still be a problem as under the current system, since the information on 

passengers surrendering/purchasing a ticket on board, that is available at CNOC, will always be 

one station behind. 

Costs of Automated Onboard Ticket Collection System 

Table 8 shows the one-time costs and annual ongoing costs associated with this alternative, along 

with the quantities and types of equipment needed to implement the alternative. One-time costs 

for required hardware and software were estimated as $29,300,000 to $50,300,000. Ongoing 

costs were estimated as $2,700,000 to $4,900,000 per year. 
69

Table 8. Automated Onboard Ticket Collection System 

Cost Element Unit Cost (dollars) Quantity Total Cost (dollars) 

Low High Low High One 

Vehicle-Related Costs 

Data communications system to/from train for each train

200 400 336 67,000 134,000

Onboard computer hardware and software for each train 

4,600 5,600 336 1,546,000 1,882,000

Portable (handheld) ticket scanner with ticket issue capability for each conductor 

2,400 3,900 728 1,747,000 2,839,000

Station-Related Costs 

Ticket vending machine at select stations 29,000 58,100 72 2,088,000 4,183,000 Booking office machines for all stations with staffed ticket offices 

11,800 310 

3,658,000 3,658,000

Station hardware/software at each station 6,400 9,200 515 3,296,000 4,738,000 Central hardware/software 2,759,000 1 2,759,000 2,759,000 Data communications system to/from train for each station 

200 400 515 103,000 206,000 

Communications infrastructure linking station computers and CNOC 

6,798,000 1 6,798,000 6,798,000 

Fare Media Costs 

Ticket media per ticket 0.02 0.04 11,606,000 232,000 464,000 
70

Table 8. Automated Onboard Ticket Collection System (continued)

Cost Element Unit Cost (percent) Quantity Total Cost (dollars) 

Low High Low High On

Variable System Costs Spare Parts (% of equipment cost) 10 15 - 2,206,000 4,080,000 Support services include training, documentation, revenue testing, and warranties (% of equipment cost) 

10 15 - 2,206,000 4,080,000 

Installation (% of equipment cost) 3 10 - 662,000 2,720,000 Nonrecurring engineering and software costs (% of equipment cost) 

0 30 - 0 8,159,000 

Contingency (% of equipment/operating cost) 10 15 - 2,206,000 4,080,000 Equipment maintenance costs (% of equipment cost) 5 7 - 1,103,000 1,904,000 Software licenses/system support (% of systems/software cost) 

15 20 - 1,140,000 1,876,000 

One Time Costs 29,342,000 50,315,000 Total Annual Ongoing Costs 2,723,000 4,880,000 
71

7.2.4 Automated Onboard Ticket Collection System with Improved Information Transfer 

System Description 

Under this alternative a handheld device would be used to scan tickets and passes, and issue 

tickets. All non-revenue passengers would have or be issued a ticket or pseudo ticket. All 

tickets and passes issued by ticket machines, ticket offices, travel agents, and on board would 

have a consistent machine readable format. The latest version of the passenger list, including the 

latest list of ticketed and unticketed individuals scheduled to board at the upcoming station 

would be transmitted to the train from CNOC just before the train’s arrival at the station. Upon 

completion of the ticket lift, the passenger data would be downloaded to an onboard computer, 

and would then be transmitted to CNOC where the manifest would be updated, and a revised 

manifest would be transmitted back to the train. Data transmission would be via satellite or 

cellular technology. Current practice of allowing onboard sales would continue since tickets 

would not be checked prior to boarding. 

Advantages/Disadvantages of Automated Onboard Ticket Collection System with 

Improved Information Transfer

This alternative would have an advantage over the current system because it would provide name 

information for all passengers including pass holders and onboard sales, would account for 

passholders and onboard sales in the manifest update, would account for no-shows at each 

station, and would ensure that the manifest was updated after completion of the ticket lift 

following each station stop. This approach would allow for real time or near real time 

verification of reservations/payment for unticketed passengers. 

This system addresses some of the problems in the current system related to actual practice 

versus stated policy and addresses an inherent defect in the current system, which is timeliness 

(the one-station-behind problem) of updates to the manifest. However, a complete list of 

passenger tickets scanned/issued would not be available in the interval between the train 

departing the station and completion of the ticket lift. 

The manifest produced under this alternative would provide a list of passenger tickets 

scanned/issued by the conductor after completion of the ticket lift, less scheduled departures at 

the given station stop. This may or may not be a list of passengers on the train at that point due 

to potential fare evaders, conductor mistake, or premature departure (potential security concern). 

This approach does not meet NTSB requirements. This system will not capture people leaving 

before their scheduled stop or those missed by the conductor in the ticket lift. Timeliness of 

information would still be a problem, since a ticket lift takes time, and no guarantee exists that an 

accident would not occur after station departure but before transmittal of the updated passenger 

information from the train to CNOC. 
72

Associated Costs of Automated Onboard Ticket Collection System with Improved 

Information Transfer 

Table 9 shows the one-time costs and annual ongoing costs associated with this alternative, along 

with the quantities and types of equipment needed to implement the alternative. One-time costs 

for required hardware and software were estimated as $17,000,000 to $31,200,000. Ongoing 

costs were estimated as $1,600,000 to $2,900,000 per year. These costs do not include the costs 

of the satellite/cellular infrastructure. 
73

Table 9. Automated Onboard Ticket Collection System with Improved Information Transf

Cost Element Unit Cost (dollars) Quantity Total Cost (dollars) 

Low High Low High 

Vehicle-Related Costs 

Data communications system to/from train for each train 

1,100 2,100 444 488,000 932,000 

Onboard computer hardware and software for each train 

4,600 5,600 336 1,546,000 1,882,000 

Portable (handheld) ticket scanner with ticket issue capability for each conductor 

2,400 3,900 728 1,747,000 2,839,000 

Station-Related Costs 

Ticket vending machine at select stations 29,000 58,100 72 2,088,000 4,183,000 Booking office machines for all stations with staffed ticket offices 

11,800 310 3,658,000 3,658,000 

Central hardware/software 2,759,000 1 2,759,000 2,759,000 

Fare Media Costs 

Ticket media per ticket 0.02 0.04 11,606,000 232,000 464,000 
74

Table 9. Automated Onboard Ticket Collection System with Improved Information Transfer (c

Cost Element Unit Cost (percent) Quantity Total Cost (dollars) 

Low High Low High O

Variable System Costs Spare Parts (% of equipment cost) 10 15 - 1,229,000 2,438,000 Support services include training, documentation, revenue testing, and warranties (% of equipment cost) 

10 15 - 1,229,000 2,438,000 

Installation (% of equipment cost) 3 10 - 369,000 1,625,000 Nonrecurring engineering and software costs (% of equipment cost) 

0 30 - 0 4,876,000 

Contingency (% of equipment/operating cost) 10 15 - 1,229,000 2,438,000 Equipment maintenance costs (% of equipment cost) 5 7 - 614,000 1,138,000 Software licenses/system support (% of systems/software cost) 

15 20 - 646,000 928,000 

One Time Costs 16,955,000 31,207,000 Total Annual Ongoing Costs 1,641,000 2,910,000 
75

7.2.5 Electronic Tickets with Platform Gate Readers and Car Door Readers 

System Description 

Under this alternative the platform area at all currently staffed stations would be sealed off. 

Passengers would not be allowed to enter or exit the platform area without a valid ticket. 

Readers on the gates would be used to read the tickets of passengers getting on and off the 

platform. Entry to the platform area would not be allowed until all debarking passengers had 

exited the platform area. Station personal would be required to assist passengers and ensure 

compliance. At unstaffed stations, readers at select car doors would be used to read tickets of 

passengers getting on and off the train. The only operable doors would be those monitored by 

the crew, which implies only two or three doors used per train. This should not cause delays 

given the low passenger volumes at unstaffed stations. 

All passengers would be required to have a ticket before boarding. Onboard ticket sales would 

be eliminated. All non-revenue passengers would have a ticket or pseudo ticket. Tickets would 

likely be disposable contactless smart cards,61 eliminating the need for passengers to insert their 

ticket into some sort of device and then retrieve their ticket. Tickets would contain data on 

origin, destination, fare, type of passenger (full fair, child, Amtrak employee), name, and other 

personal information deemed appropriate. Ticket vending machines (TVMs) or a ticket office 

would be required at all stations.62 Conductors would no longer be part of the revenue/ticket 

collection process, with an increased customer service/safety role. However, conductors would 

monitor active doors at unstaffed stations to ensure that all passengers were in possession of a 

valid ticket. 

The latest version of the passenger list, including the latest list of individuals holding tickets to 

board at the upcoming station, would be transmitted to the station from CNOC just prior to the 

train’s arrival. All tickets would be processed at the gates or at the car door. All boardings and 

alightings would be accounted for before the train departed the station. An updated manifest (list 

of passengers on board) would be transmitted to a station computer via WIFI technology prior to 

departure from the station and then on to CNOC. 

Advantages/Disadvantages of Electronic Tickets with Platform Gate Readers and Car Door 

Readers 

This alternative meets NTSB requirements (and potential TSA requirements) because it provides 

a list of passengers on the train as it departed the station that is valid until arrival at the next 

 

61 A disposable contactless smart card would be made of paper and contain a small imbedded computer chip 

containing the relevant ticket information. The ticket information is transferred by means of radio frequency 

transmission. The card contains a radio transponder that is activated only upon receipt of a specific radio frequency. 

Upon activation, the card generates a response that acts as an identifier. 

62 In remote station areas, banks or local retail outlets could serve as Amtrak ticket agents on a commission basis. 

These outlets could serve as a substitute for an Amtrak ticket office or ticket vending machine. The cost of this 

option was not estimated for the current analysis. 
76

station. A copy of this list would reside at the CNOC, and a copy would be available to the train 

crew. 

This alternative would necessitate a radical change in Amtrak’s way of doing business. All 

passengers would be required to have a ticket prior to boarding, even if it were a zero fare ticket. 

No onboard sales and no Form 3085s would exist. Amtrak multiride passes would be just 

another form of ticket. Commuter railroad passholders would need to present their pass and 

identification at a ticket office to get a ticket, or the policy of honoring commuter railroad passes 

on selected Amtrak reserved trains would have to be abolished. (Commuter rail passholders 

would not be able to get a ticket at unstaffed stations.) Reservation and ticket issuing processes 

would remain unchanged otherwise. Revenue accounting would be done at each station stop as 

passengers enter/exit the platform area or train. 

Costs for Electronic Tickets with Platform Gate Readers and Car Door Readers 

Table 10 shows the one-time costs and annual ongoing costs associated with this alternative, 

along with the quantities and types of equipment needed to implement the alternative. In 

addition to the fare gates, various modifications would be required to segregate the platform 

boarding area from the rest of the station. 

The cost elements for typical station modifications required to go to a gated system include the 

following: 

• Removal of existing fencing, gates, walls, and concessions to clear access to the control 

area and enlarge space for fare gates. 

• Relocation of station furniture, such as waiting room benches, advertising displays, 

directional and information panels, and trash containers. 

• Installation of power and communication lines encased in partitioned wireway or rigid 

conduit, and addition of electrical panels with switches/circuit breakers. 

• Installation of fare gates and TVMs, including concrete mounting pads and anchor bolts, 

but excluding the hookup and startup testing of the machinery, which is usually done by 

the equipment manufacturer as part of the equipment purchase price. 

• Fencing of the station fare control areas and platforms and installation of gates, not 

including the capital cost of the remotely controlled service gates installed in the fare gate 

arrays. 

• Construction or major renovation of doorways, stairways, footbridges, passageways, 

equipment shelters, and ticket offices.63

 

63 Grenzeback, Lance R. and Tomasz M. Wiktor, Evaluation of Automatic Fare Collection Technology – Volume 

IVB – Station and Vehicle Modifications: Commuter Rail, prepared for New York Metropolitan Transportation 

Authority, Arthur D. Little, Inc., Cambridge, Massachusetts, November 1984. 
77

One-time costs for required hardware and software and station modifications to 211 stations 

were estimated as $130,700,000 to $208,500,000. Ongoing costs were estimated as $7,200,000 

to $21,200,000 per year. 

If only the top 20 stations (in terms of passenger volume) were equipped with gates, then the 

estimated one-time costs would range from $63,200,000 to $127,000,000, while ongoing costs 

would range from $6,800,000 to $20,100,000 per year. 
78

Table 10. Electronic Tickets with Platform Gate Readers and Car Door Readers 

Cost Element Unit Cost (dollars) Quantity Total Cost (dollars) 

Low High Low High On

Vehicle-Related Costs 

Stand-alone smart card processing unit for each operable car door 

1,000 6,800 2,108 2,108,000 14,334,000 

Data communications system to/from train for each train 

200 400 336 67,000 134,000 

Onboard computer hardware and software for each train 

4,600 5,600 336 1,546,000 1,882,000 

Station-Related Costs 

Ticket vending machine at select stations 29,000 58,100 359 10,411,000 20,858,000 Booking office machines for all stations with staffed ticket offices 

11,800 310 3,658,000 3,658,000 

Bidirectional fare gate (contactless card) 19,400 33,900 443 8,594,000 15,018,000 Station hardware/software for all stations 6,400 9,200 515 3,296,000 4,738,000 Central hardware/software 2,759,000 1 2,759,000 2,759,000 Data communications system to/from train for each station 

200 400 515 103,000 206,000 

Communications infrastructure linking station computers and CNOC 

6,798,000 1 6,798,000 6,798,000 

Station modifications required to go to a gated system 

 78,332,000 78,332,000 

High Cost Station - 1,037,100 20 20,742,000 20,742,000 Moderate Cost Station - 581,200 56 32,547,000 32,547,000 Low Cost Station - 185,500 135 25,042,000 25,042,000 

Fare Media Costs 

Contactless disposable smart cards per card 0.3 1 11,606,000 3,482,000 11,606,000 
79

Table10. Electronic Tickets with Platform Gate Readers and Car Door Readers (continu

Cost Element Unit Cost (percent) Quantity Total Cost (dollars) 

Low High Low High One

Variable System Costs Spare Parts (% of equipment cost) 10 15 - 3,934,000 10,558,000 Support services include training, documentation, revenue testing, and warranties (% of equipment cost) 

10 15 - 3,934,000 10,558,000 

Installation (% of equipment cost) 3 10 - 1,180,200 7,038,000 Nonrecurring engineering & software costs (% of equipment cost) 

0 30 - 0 21,116,000 

Contingency (% of equipment/operating cost) 10 15 - 3,934,000 10,558,000 Equipment maintenance costs (% of equipment cost) 5 7 - 1,967,000 4,927,000 Software licenses/system support (% of systems/software cost) 

15 20 - 1,140,000 1,876,000 

One Time Costs 130,654,000 208,544,000 Total Annual Ongoing Costs 7,248,000 21,170,000 
80

7.2.6 Electronic Tickets with Car Door Readers 

System Description 

Under this alternative, car doors would be equipped with readers to read tickets of passengers 

getting on and off trains. The only operable doors would be those monitored by the crew, which 

implies only two or three doors used per train. This could result in potential delays at major 

stations with substantial numbers of passengers boarding and alighting each train, although the 

technology allows for the rapid processing of passengers as they board and depart. 

All passengers would be required to have a ticket prior to boarding. Onboard ticket sales would 

be eliminated. All non-revenue passengers would have a ticket or pseudo ticket. Tickets would 

be disposable contactless smart cards, eliminating the need for passengers to insert their ticket 

into some sort of device and then retrieve their ticket. Tickets would contain data on origin, 

destination, fare, type of passenger (full fair, child, Amtrak employee, etc.), name, and other 

personal information deemed appropriate. Ticket machines or a ticket office would be required at 

all stations. Conductors would be effectively out of the revenue/ticket collection loop, with an 

increased customer service/safety role. However, conductors would monitor active doors in 

order to ensure that all passengers were in possession of a valid ticket. 

The latest version of the passenger list including the latest list of individuals holding tickets to 

board at the upcoming station would be transmitted to the station from CNOC just prior to the 

train’s arrival. All tickets would be processed at the car door. All boardings and alightings 

would be accounted for prior to the train departing the station. An updated manifest (list of 

passengers on board) would be transmitted to a station computer via WIFI technology prior to 

departure from the station and then on to CNOC. 

Advantages/Disadvantages of Electronic Tickets with Car Door Readers 

This alternative meets NTSB requirements (and potential TSA requirements) in that it provides a 

list of passengers on the train as it departed the station that is valid until arrival at the next 

station. A copy of this list would reside at the CNOC and a copy would be available to the train 

crew. 

Like the previous alternative, this alternative would also necessitate a radical change in Amtrak’s 

way of doing business. All passengers would be required to have a ticket prior to boarding, even 

if it were a zero fare ticket. There would be no onboard sales and no Form 3085s. Amtrak 

multiride passes would be just another form of ticket. Commuter railroad passholders would 

have to present their pass and identification at a ticket office in order to get a ticket, or the policy 

of honoring commuter railroad passes on selected Amtrak reserved trains would have to be 

abolished (Commuter rail passholders would not be able to get a ticket at unstaffed stations). 

Reservation and ticket issuing processes would remain unchanged otherwise. Revenue 

accounting would be done at each station stop as passengers enter/exit the train. 
81

Costs for Electronic Tickets with Car Door Readers 

Table 11 shows the one-time costs and annual ongoing costs associated with this alternative, 

along with the quantities and types of equipment needed to implement the alternative. One-time 

costs for required hardware and software were estimated as $40,900,000 to $102,400,000. 

Ongoing costs were estimated as $6,800,000 to $20,000,000 per year. 
82

Table 11. Electronic Tickets with Car Door Readers 

Cost Element Unit Cost (dollars) Quantity Total Cost (dollars) 

Low High Low High On

Vehicle-Related Costs 

Stand-alone smart card processing unit for each operable car door 

1,000 6,800 2,108 2,108,000 14,334,000 

Data communications system to/from train for each train 

200 400 336 67,000 134,000 

Onboard computer hardware and software for each train 

4,600 5,600 336 1,546,000 1,882,000 

Station-Related Costs 

Ticket vending machine for all stations 29,000 58,100 359 10,411,000 20,858,000 Booking office machines for all stations with staffed ticket offices 

11,800 310 3,658,000 3,658,000 

Station hardware/software for all stations 6,400 9,200 515 3,296,000 4,738,000 Central hardware/software 2,759,000 1 2,759,000 2,759,000 Data communications system to/from train for each station 

200 400 515 103,000 206,000 

Communications infrastructure linking station computers and CNOC 

 6,798,000 1 6,798,000 6,798,000 

 

Fare Media Costs 

Contactless disposable smart cards per card 0.3 1 11,606,000 3,482,000 11,606,000 
83

Table 11. Electronic Tickets with Car Door Readers (continued)

Cost Element Unit Cost (percent) Quantity Total Cost (dollars) 

Low High Low High One 

Variable System Costs Spare Parts (% of equipment cost) 10 15 - 3,075,000 8,305,000 Support services include training, documentation, revenue testing, and warranties (% of equipment cost) 

10 15 - 3,075,000 8,305,000 

Installation (% of equipment cost) 3 10 - 922,000 5,537,000 Nonrecurring engineering and software costs (% of equipment cost) 

0 30 - 0 16,610,000 

Contingency (% of equipment/operating cost) 10 15 - 3,075,000 8,305,000 Equipment maintenance costs (% of equipment cost) 5 7 - 1,537,000 3,876,000 Software licenses/system support (% of systems/software cost) 

15 20 - 1,140,000 1,876,000 

One Time Costs 40,892,000 102,430,000 Total Annual Ongoing Costs 6,775,000 19,961,000 
84

7.3 Potential Benefits of Electronic Ticketing 

All of the alternatives considered above (except one) involve some form of electronic or machine 

readable ticket. As noted in the companion report of this study,64 it would be difficult to justify 

the cost of any passenger manifest system on the basis of lives potentially saved, or reduced 

search and rescue costs. It may be possible, however, to justify the investment cost of a new 

reservation/ticketing/revenue accounting process which includes the capability of meeting NTSB 

requirements for a passenger accountability system, based on a reduction in operating costs and 

the value of better information (planning data, reduced liability claims, yield management). 

A basic premise of this analysis is that any passenger manifest system will not exist in a vacuum. 

Its costs and benefits must be tied into the overall passenger reservation, ticketing and revenue 

accounting systems, and also into the role of the conductors. This later consideration involves a 

potential trade-off between their part in the ticket sale, ticket collection and revenue accounting 

process, and alternative roles in ticket enforcement, safety, security, and customer service. 

Alternative models for the role of conductors include the U.S. commuter railroads using proofof-payment (POP) ticket systems,65 and the Japanese and French railroads. 

Automation of Amtrak’s ticketing procedures can be viewed as similar to efforts undertaken by 

various urban transit agencies in implementing automatic fare collection (AFC) systems. 

Proponents of AFC have noted that potential cost savings are possible in moving to an automated 

revenue collection and processing system. A detailed analysis of Amtrak’s current cost of 

reservations, ticket sales, ticket collection, and revenue processing versus those of any proposed 

system would be required in order to determine if in fact there were any cost savings that could 

be attributed to the automated system. 

The costs of fare collection and revenue processing can be substantial. It was not possible to 

derive an actual figure for revenue collection and processing from Amtrak’s published financial 

data. However, a rough estimate can be derived from data on commuter railroads where various 

studies have indicated that the cost of fare collection ranged from 1.8 percent to 27 percent of 

ticket revenue.66 The commuter rail costs include labor, materials, and services associated with 

 

64 Mauri, Ronald and Joseph Mergel, Amtrak Passenger Accountability System, Baseline Description and 

Emergency Response Uses of Passenger Information, DRAFT, prepared for the Federal Railroad Administration, 

Volpe National Transportation Systems Center, Cambridge, Massachusetts, September 2004. 

65 VRE (Virginia Railway Express) Alexandria, Virginia, TRE (Trinity Railway Express) Dallas, Texas, Metrolink 

(Southern California Regional Rail Authority) Los Angeles, California, Coaster (North County Transit District) 

Oceanside, California, Tri-Rail (South Florida Regional Transportation Authority) Pompano Beach, Florida, and 

CALTRAIN (Peninsula Corridor Joint Powers Board) San Carlos, California. 

66 Metz, Peter J., et al., Evaluation of Automatic Fare Collection Technology – Volume IB – Summary, Conclusions, 

and Recommendations: Commuter Rail, prepared for New York Metropolitan Transportation Authority, Arthur D. 

Little, Inc., Cambridge, Massachusetts, November 1984, p.12. 

The annual operating and maintenance cost of fare collection represent 26 percent of passenger revenues on 

the LIRR (Long Island Rail Road) and 20 percent on the MNCR (Metro-North Commuter Railroad). This 

cost includes the wages and benefits of all fare collection personnel, materials and supplies, services and a 

small amount of revenue from bad checks. The duties of trainmen include pass and ticket inspection, ticket 
85

the production and distribution of the fare media, as well as collection and processing. In FY03, 

Amtrak ticket revenue was $1,180.1 million.67 Applying these percentages to Amtrak’s ticket 

revenues results in an estimated annual revenue processing cost to Amtrak of $21 million to 

$319 million. 

The effect of introducing an automated payment program on operating and maintenance costs 

will depend on changes to existing cost elements, including cost savings, and new cost elements. 

The introduction of electronic ticketing could be expected, at least in theory, to produce various 

benefits to an agency. These include: 

• Reduced fare collection costs 

• Improved revenue accounting and security in terms of improved ability to track 

transactions and discourage employee theft or mishandling of fare revenues 

• Reduced fare abuse including reduction of counterfeiting of media, short payment, or 

illegal use of media 

• Improved ridership data 

 cancellation, onboard ticket sales, and control of doors. The off-train personnel involved in fare collection 

sell tickets, supervise ticket offices, account for and audit revenues, and sell passes by mail. 

Fleishman, Daniel, Multipurpose Transit Payment Media, T C R P Report 32, Transportation Research Board, 

National Research Council, National Academy Press, Washington, D.C. 1998, p. 46.

Reports transit agency fare collection costs (based on a survey of transit agencies in June 1996) as a percent 

of fare revenues. Results for commuter rail systems indicate a range of media production and distribution 

costs of 0.2 – 7.0 percent (average 2.7 percent), a range of collection and processing costs of 1.6 – 15 

percent (average 9.2 percent) with total cost of 1.8 – 22 percent (average 11.9 percent) of fare revenues. 

Systems surveyed were: Tri-Rail (Ft. Lauderdale), SCRRA (Los Angeles), MNCRR (New York), GO 

Transit (Toronto), and BC Transit (Vancouver). With the exception of MNCRR, all systems are proof-ofpayment (POP) operations. 

Commuter Rail Fare Collection, A Comprehensive Strategy for Improvements, prepared for New Jersey Transit 

Corporation, Ernst & Whitney, December 1982, p. III-21. 

Major direct cost elements related to ticket sales and fare collection include: onboard ticket collection 

labor, station agent labor, and administrative costs. The overall cost relating to ticket sales, fare collection, 

and revenue accounting was 27 percent of revenues. Train crew labor made up 65 percent of these costs 

(with an average of 2.7 conductors per train). 

The cost of revenue processing (station agents, revenue accounting and control) at NJTC was 9 percent of 

revenues. This compared to 5 percent at the B&M (Boston) and 17 percent at GO (Toronto). 

67 National Railroad Passenger Corporation and Subsidiaries (Amtrak) Consolidated Financial Statements, 

September 30, 2003 and 2002, (With Independent Auditor’s Report Thereon), KPMG LLP, McLean, Virginia, 

February 25, 2004. 
86

• Reduced data collection costs 

Actual data on documented benefits of AFC systems in the urban transit arena are scarce and 

results are inconclusive as indicated in the examples below. 

Comprehensive analyses of the cost effects of implementing multipurpose fare systems were 

undertaken as part of the Central Puget Sound and Bay Area TransLink regional fare studies. The 

former study compared new and existing costs for the King County Metro transit system and 

estimated that the effect of the recommended smart card system on Metro’s fare collection 

operating and maintenance costs could range from an increase of $139,000 per year (roughly 4 

percent of the total annual current cost) to a reduction of $309,000 (more than 9 percent of the 

current total). 

The TransLink study compared the costs associated with existing fare collection for the entire 

region with the estimated TransLink implementation and operation costs. The study determined 

that TransLink would result in total 5-year costs approximately 4 percent lower than comparable 

costs for the existing system, producing a savings of more than $1.5 million over the 5-year 

analysis period.68

However, a rough cost benefit analysis of a smart card-based AFC for Toronto concluded that, 

given the circumstances then prevailing in Toronto, one could not make a good business case for 

the system. The report notes, “In all the AFC systems which staff visited and which were in 

actual operation, there were insufficient operating costs savings to offset the capital investment 

required for the system.”69

This same report notes that TTC staff visited a number of cities that have implemented, or are in 

the process of testing or implementing AFC systems. The purpose of the visits was to determine 

what these cities were trying to achieve by implementing an AFC system. 

The major reason given for implementing or testing new systems was to address the problem of 

ageing or failing fare collection equipment. Every city visited had been driven to seek out new 

fare collection equipment because their existing equipment was old and at the end of its usable 

economic life. 

Amtrak’s latest strategic plan70 notes that Amtrak has reached this point in regard to its 

reservation, and ticketing systems, and is considering the implementation of electronic ticketing 

(see Appendix A). 

An improved passenger accountability system may be viewed as an ancillary benefit associated 

with an improved overall ticket sales, distribution, collection and post processing system. 

 

68 Fleishman, Daniel, Multipurpose Transit Payment Media, T C R P Report 32, Transportation Research Board, 

National Research Council, National Academy Press, Washington, D.C. 1998.

69 TTC Fare Collection Study, Toronto Transit Commission, October 2000. 

70 Amtrak Strategic Plan FY 2005-2009, June 29,2004. 
87

7.4. Conclusions 

• Improved passenger accountability systems may have benefits (cost savings) within the 

overall ticket reservation/sales/collection/revenue accounting function, but Volpe Center 

staff did not quantify them as part of this study. 

• A detailed analysis of the total costs of Amtrak’s current ticket 

reservation/sales/collection/revenue accounting function would be required along with an 

estimate of the total cost of the proposed alternatives in order to make a business case for 

an automated alternative. 

• Cost estimates presented in this study are partial costs only (i.e., the marginal or 

incremental costs of the automated alternatives). 

• Of four alternatives considered, the two least costly would not meet NTSB requirements 

although they also involved significant costs. 

• A system based on disposable smart card tickets and door mounted ticket readers would 

meet NTSB requirements and cost less than an alternative that relied on gated platforms. 

• Amtrak is at a point where requirements for a passenger accountability system can be 

incorporated into planned improvements to ticketing, stations, rolling stock, and support 

functions. 

If viewed as a stand-alone system, the safety benefits of a passenger accountability system are 

negligible, while the costs of implementing and operating the system on a stand-alone basis are 

substantial. However, when placed in the context of the overall process associated with the 

production, distribution, sales, collection, and processing of fare media, and given that Amtrak 

has or is planning on embarking on a major overhaul of what they consider an outdated system, 

the marginal costs of producing a passenger manifest that meets the NTSB’s requirements may 

prove to be manageable. Amtrak should be encouraged to include considerations related to 

producing an improved manifest system as they proceed with their strategic plans for marketing 

and sales and transportation support systems. (see Appendix A for relevant excerpts from 

Amtrak’s Strategic Plan). 

If the NTSB is to be taken literally, any passenger manifest must provide information on the 

number and identity of passengers on board at all times. 

The current system does not meet these requirements and cannot be made to meet these 

requirements, even with extensive automation. 

Identified deficiencies in the current process imply that to meet the NTSB recommendation, all 

boarding passengers must have a ticket or pass containing their identity before boarding (no 

onboard sales), these tickets must be checked/validated prior to train movements, and the number 
88

of passengers boarding and their identity must be made available to Arrow (or its replacement) 

prior to the train departing the station. 

In addition, all departing passengers would have to have their tickets checked/validated, so that 

the number of passengers departing the train and their identity is made available to Arrow before 

the train departs the station. 

Only a system that accounts for ons and offs, tracks named, individual tickets, and updates to 

produce a passenger list prior to the train’s departure from a station will meet NTSB 

recommendations. 

Implementation will require a change in Amtrak’s business model i.e., no onboard ticket sales, 

no passengers allowed to board without a ticket, and a change in policy on honoring passes of 

commuter railroads. Commuter rail passholders would be required to get a ticket before 

boarding. This is the current policy for Amtrak passholders wishing to ride the Acela Express or 

Metroliners. 

A basic premise of this analysis is that any passenger manifest system will not exist in a vacuum. 

Its costs and benefits are tied into the overall passenger reservation, ticketing and revenue 

accounting systems, and into the role of the conductors. This later consideration involves a 

potential trade-off between their part in the ticket sale, ticket collection and revenue accounting 

process, and alternative roles in safety, security, and customer service. Alternative models for the 

role of the conductor include the POP commuter railroads, the Japanese, and French railroads.71

It will be difficult to justify the cost of any passenger manifest system on the basis of lives 

potentially saved, or reduced search and rescue costs. However, it may be possible to justify the 

investment cost of a new reservation/ticketing/revenue accounting process which includes the 

capability of meeting the NTSB requirements for a passenger manifest system, based on a 

reduction in operating costs and the value of better information (planning data, reduced liability 

claims, yield management). 

An improved passenger accountability system may be viewed as an ancillary benefit associated 

with an improved overall ticket sales, distribution, collection, and post processing system. 

All alternatives considered here, other than the base case or “do nothing” alternative, will require 

increased costs over the base case, and some will result in a system that does not meet NTSB 

requirements. 

The improved base case would require draconian enforcement of the stated policies related to 

onboard passenger-accounting procedures (i.e., a system-wide audit to determine the extent of 

non-compliance by conductors, followed by enforcement measures to ensure full compliance). 

 

71 Note that POP ticketing is used on various commuter railroads including VRE, TRE, Metrolink, Coaster, TriRail, and CALTRAIN. The conductor’s role is one of enforcement rather than fare collection. Under POP, there are 

no onboard sales. Passengers must have a valid ticket. Not having a valid ticket results in a substantial fine. 
89

This case would also involve increased station staffing levels and increased crew size on certain 

reserved trains. 

Table 12 summarizes one-time costs and annual ongoing costs for the alternatives discussed in 

the previous section. The least costly alternative both in terms of first costs and ongoing costs is 

Alternative 2, which is based on conductors using handheld devices to collect ticket information, 

and the transfer of the passenger list to/from the CNOC using satellite/cellular technology. The 

most costly alternative is Alternative 3, which is based on gated staffed stations and the use of 

door readers at unstaffed stations. As noted in the previous section, however, Alternatives 1 and 

2 cannot meet the NTSB’s stated requirements for a passenger accountability system. Of the 

considered alternatives that do meet NTSB requirements, Alternative 4 (based on door mounted 

ticket readers) is the least costly. 

Table 12. Alternative Systems’ Cost Summary 

One-Time Costs (dollars) Total Annual Ongoing 

Costs (dollars) 

Alternative 

Low High Low High 

1-Automated Onboard Ticket Collection 

System 29,300,000 50,300,000 2,700,000 4,900,000

2-Automated Onboard Ticket Collection 

System with Improved Information Transfer 17,000,000 31,200,000 1,600,000 2,900,000

3-Electronic Tickets with Platform Gate 

Readers and Car Door Readers 131,000,000 208,500,000 7,200,000 21,200,000

3a-Electronic Tickets with Platform Gate 

Readers (at Top 20 Stations Only) and Car 

Door Readers 63,200,000 127,000,000 6,800,000 20,100,000

4-Electronic Tickets with Car Door Readers 40,900,000 102,400,000 6,800,000 20,000,000

The estimated annual ongoing costs should be considered in light of Amtrak’s current revenue 

handling costs. It was not possible to derive actual figures for revenue collection and processing 

from Amtrak’s published financial data. However, information from commuter railroads 

indicates that Amtrak may be spending from 2 percent to over 25 percent of annual ticket 

revenues on revenue collection and processing. In FY03, Amtrak’s ticket revenue was $1,180.1 

million.72 Thus, Amtrak may be currently spending $21 to $319 million on costs related to ticket 

sales, fare collection, and revenue accounting with the more likely figure tending toward the high 

end of the scale. The lower figure is representative of POP operations while the higher figure is 

representative of more conventional operations involving ticket collection and onboard sales by 

conductors. 

While there are negligible safety benefits to having an improved manifest system, there may be 

potential operating cost savings in implementing an electronic ticketing/AFC system which 

would be capable of also providing a passenger accountability function that met NTSB 

 

72 National Railroad Passenger Corporation and Subsidiaries (Amtrak) Consolidated Financial Statements, 

September 30, 2003 and 2002, (With Independent Auditor’s Report Thereon), KPMG LLP, McLean, Virginia, 

February 25, 2004. 
90

requirements. It was not possible to prepare a detailed estimate of potential savings within the 

scope of this current project.

In order to place the one-time costs of a passenger accountability system in context consider the 

following from Amtrak’s latest strategic plan.73 

Capital Needs FY05-FY09

Infrastructure $2,123 million 

Fleet $1,476 million 

System Support $394 million 

Infrastructure includes $171 million in station improvements, primarily deferred maintenance 

and Americans with Disabilities Act (ADA) requirements. Station modifications required under 

Alternative 3 (gated stations), were estimated at $20.7 million to $78.3 million depending on the 

number of stations outfitted with ticket-reading gates. 

Fleet includes $745 million in existing fleet overhaul of passenger cars, and $380 million in new 

equipment acquisition. (Heritage replacements, rail diesel cars, next generation corridor 

equipment, and auto carriers) 

One-time vehicle-related costs under both Alternative 3 and 4 were estimated at $3.7 million to 

$16.3 million. 

There would seem to be opportunities for cost sharing between the requirements for an improved 

manifest system and Amtrak’s current capital investment plans in the area of station modification 

and car replacement/rehabilitation. 

System Support includes environmental, marketing/sales, police, procurement, real estate, 

transportation, finance, planning, and technology. The relevant items from the Strategic Plan are 

information technology, planning, and finance at $94 million, transportation at $60 million, and 

marketing/sales at $ 47 million for a total of $201 million. 

One-time costs for station-related and central hardware/software were estimated to vary from 

$37.4 million under the alternative utilizing onboard door ticket readers to $118.6 million under 

the alternative based on a mix of gated stations and onboard door ticket readers. 

The major reason given for implementing new fare collection systems in urban transit systems 

has been that existing systems were at the end of their usable economic lives. As indicated in its 

Strategic Plan, Amtrak appears to be approaching this point with its current ticketing and 

reservation systems. 

There would also seem to be opportunities for cost sharing between the requirements for a 

manifest system and Amtrak’s current investment plans in the area of System Support. 

 

73 Amtrak Strategic Plan FY 2005-2009, June 29,2004. 
91

As a result of this preliminary analysis it would be desirable for Amtrak to consider whether 

meeting NTSB’s passenger accountability recommendation can be accomplished as part of its 

more general plans for system improvements. Amtrak could consider the following possible 

solutions: 

• As part of any effort to upgrade its passenger accounting systems, Amtrak could initiate a 

more detailed study of the potential costs and benefits of implementing a passenger 

accountability system based on electronic tickets with car door readers, in conjunction 

with implementation of planned programs of fleet replacement, station modernization, 

and support system development. 

• Amtrak should define its end-state reservation, ticketing, and passenger accountability 

systems, and then incorporate the associated requirements for an improved passenger 

accountability system into its planned programs of fleet replacement, station 

modernization, and support system development, even if they do not meet all aspects of 

the NTSB recommendation.

93

Bibliography 

Amtrak Train 87 Derailment after Colliding with Intermodal Trailer from CSXT Train 176 

Selma, North Carolina, May 16, 1994, NTSB Report Number RAR-95-02, adopted on 

3/21/1995. 

Amtrak, Service Standards Manual for Train Service & On-Board Service Employees, May 3, 

2004. 

Collision and Derailment of Maryland Rail Commuter MARC Train 286 and National Railroad 

Passenger Corporation AMTRAK Train 29 Near Silver Spring, Maryland, February 16, 1996, 

NTSB Report Number RAR-97-02, adopted on 6/17/1997. 

Collision of Amtrak Train No. 88 with Rountree Transport and Rigging, Inc., Vehicle on CSX 

Transportation, Inc., Railroad near Intercession City, Florida, November 30, 1993, NTSB 

Report Number HAR-95-01, adopted on 5/16/1995. 

Collision of Amtrak Train No. 90 and MARC Train No. 437, Baltimore, Maryland, June 17, 

2002, NTSB Report Number RAB-03-01, adopted on 5/12/2003. 

Collision of National Railroad Passenger Corporation (Amtrak) Train 59 with a Loaded TruckSemitrailer Combination at a Highway/Rail Grade Crossing in Bourbonnais, Illinois, March 15, 

1999, NTSB Report Number RAR-02-01, adopted on 2/5/2002. 

Collision of Northern Indiana Commuter Transportation District Train 102 with a TractorTrailer Portage, Indiana, June 18,1998, NTSB Report Number RAR-99-03, adopted on 

7/26/1999. 

Derailment of Amtrak Auto Train on the CSXT Railroad near Crescent City, Florida, April 18, 

2002, NTSB Report Number RAR-03-02, adopted on 8/5/2003. 

Derailment of Amtrak Train 49 On Conrail Trackage near Batavia, New York, on August 3, 

1994, NTSB Report Number RAR-96-02, adopted on 7/11/1996. 

Derailment of Amtrak Train No. 2 on the CSXT Big Bayou Canot Bridge near Mobile, Alabama, 

September 22, 1993, NTSB Report Number RAR-94-01, adopted on 9/19/1994. 

Grade Crossing Collision, National Railroad Passenger Corporation (Amtrak) with Coastal 

Transport Tractor-Semitrailer, Jacksonville, Florida, February 5, 1997, NTSB Report Number 

RAB-01-01, adopted on 10/26/2000. 

Highway Accident Report: Report of Grade Crossing Accident Regarding a Collision Between 

an Amtrak Train and a Tractor-Trailer Combination Vehicle Intercession City, Florida, 

November 17, 2000, NTSB Report Number HAR-02-02, adopted on 7/23/2002. 
94

Railroad Accident Brief: Derailment of Amtrak Train No. 5-17 on Burlington Northern and 

Santa Fe Railway Track near Nodaway, Iowa, March 17, 2001, NTSB Report Number RAB-02-

01, adopted on 3/5/2002. 

Railroad Accident Report Derailment of Amtrak Train 4, Southwest Chief, on the Burlington 

Northern Santa Fe Railway near Kingman, Arizona, August 9, 1997 (Revision August 7, 2003), 

NTSB Report Number RAR-98-03, adopted on 8/31/1998. 

Railroad Accident Report: Collision of Amtrak Train 304-26 with a Highway Vehicle at a 

Highway-Rail Grade Crossing in McLean, Illinois, on September 26, 1999, NTSB Report 

Number RAR-01-03. 

Railroad Accident Report: Derailment of Amtrak Train 21 on the Union Pacific Railroad at 

Arlington, Texas, December 20, 1998, NTSB Report Number RAR-01-02, adopted on 

7/24/2001. 

Railroad Accident Report: Rear-End Collision of National Railroad Passenger Corporation 

(AMTRAK) Train P286 with CSXT Freight Train Q620 on the CSX Railroad at Syracuse, New 

York, February 5, 2001, NTSB Report Number RAR-01-04, adopted on 11/27/2001. 

Railroad Special Investigation Report Derailment of Amtrak Train No. 12 and Sideswipe of 

Amtrak Train No. 79 on Portal Bridge Near Secaucus, New Jersey, November 23, 1996, NTSB 

Report Number SIR-97-01, adopted on 12/18/97. 
95

Acronyms 

AFC Automatic Fare Collection 

CCJPA Capitol Corridor Joint Powers Authority 

CFR Code of Federal Regulations 

CNOC Consolidated National Operations Center 

CRS Computerized Reservation System 

FRA Federal Railroad Administration 

GPS Global Positioning System 

HHD Handheld Device 

JR Japan Railway 

LAN Local Area Network 

LCV Long Combination Vehicle 

MARC Maryland Rail Commuter 

MCFRS Montgomery County Fire and Rescue Services 

MCPD Montgomery County Police Department 

NEC Northeast Corridor 

NICTD Northern Indiana Commuter Transportation 

NTSB National Transportation Safety Board 

OBC Onboard Computer 

PCR Pre-hospital Care Report 

POP Proof of Payment 

RFI Request for Information 

RFP Request for Proposal 

ROW Right-of-Way 

SIC Station Information Computer 

SNCF French National Railways 

TGV Train à Grande Vitesse 

TSA Transportation Safety Administration 

TVM Ticket Vending Machine 

VRE Virginia Railway Express 

WIFI Wireless Fidelity 

97

Appendix A. Amtrak Manifest Samples1

 

1

 Amtrak, How to Read a Train Manifest, revised March 2004. 
98

 
99
100
101
102
103
104

 
105

Appendix B. Passenger On-Board Record Procedures from Amtrak Service 

Standards Manual for Train Service and On-Board Service Employees2

D. Passenger On-Board Record Procedures 

This section covers the procedures that must be followed on long-distance, overnight, reserved 

trains to ensure that the Conductor’s Ticket Collections Pouch provides an accurate list of 

everyone on board who may not be ticketed or appear on the manifest. 

The National Transportation Safety Board (NTSB) has further recommended that designated 

reserved overnight trains have a passenger manifest that is maintained and updated at all staffed, 

enroute boarding points. 

This standard outlines procedures for these trains. The Conductor’s Ticket Collections Pouch 

will provide an accurate list of all individuals on board who may not be ticketed or who may not 

appear on the manifest. To comply with the NTSB recommendation, the following is effective 

immediately: 

1. Requirements and Responsibilities 

a. All Conductor(s) and Assistant Conductor(s) working designated trains must pick 

up an updated manifest/Passenger Name List before reporting to their train. 

b. While the Conductor is responsible for the Train Collections Pouch, they will also 

brief other crewmembers on the location of the pouch. 

c. The Train Collection Pouch must be kept in a place that provides protection from 

heat, water, or impact damage in the event of a train emergency. 

d. In addition the Conductor will ensure Assistant Conductor(s) keep an ample 

supply of Form NRPC 3085 Passenger On-Board Record with them while on 

duty. 

e. Conductor(s) and Assistant Conductor(s) must also provide all open, staffed, 

stations with the yellow copy of any NRPC 3085 information completed and 

received from unticketed passengers and/or crewmembers while on route. This 

does not apply to large intermediate stations where station personnel are 

physically located a significant distance from the train platform, and when such 

delivery would cause delay to the train. In such cases, the yellow copy of the 

Form NRPC 3085 should be given to the designated station personnel at the final 

terminal or crew change point for entry into Arrow. At crew change points where 

no station personnel exist or are on duty, the Conductor must call the information 

in to CNOC so that the manifest information may be updated. 

f. This information is to be given to station personnel for entry into the ARROW 

system. Providing this information allows Conductor(s) to receive an updated 

Passenger Name List at the next open, staffed, station. 

 

2

Amtrak, Service Standards Manual for Train Service & On-Board Service Employees, Chapter 16 Train Service 

Crew Functions & Accountabilities, Part D Passenger On-Board Record Procedures, May 3, 2004. 
106

g. Conductor(s) can pull the passenger name list information from any ARROW 

terminal by entering SOL*N followed by the train number (e.g., SOL*N92). 

2. When to Use the Form 

a. The following are examples of persons who may not be ticketed or listed on the 

Passenger Name List manifest: 

• Infants and small children 

• Passengers purchasing tickets on board 

• Railroad officials 

• Government officials 

• Medical personnel 

• Vendors and/or contractors 

• Host railroad employees 

b. All Amtrak employees whether on business, deadheading (to or from work) or 

personal travel should have a printed ticket or must complete Form NRPC 3085. 

For those employees boarding at stations that are closed, the Conductor(s) or 

Assistant Conductor(s) must complete a Form NRPC 3085. 

c. All Amtrak employees and pass riders must provide valid Amtrak photo 

identification. 

d. In the case of an unticketed small child and/or infant, an individual Form NRPC 

3085 is also to be completed. 

e. All private car owners are required to have a Form NRPC 3085 completed for 

persons traveling providing valid photo identification. 

f. Conductor(s) and Assistant Conductor(s) must complete Form NRPC 3085 for 

any passenger or employee who has no associated transportation to lift or does not 

appear on the Passenger Name List, including passengers purchasing their tickets 

on board the train and passengers traveling in a group whose name does not 

appear on the manifest/Passenger Name List. 

g. A Form 3085 Passenger On-Board Record must be completed for each individual 

providing commentary on board the train. Those currently authorized include the 

National Park Service (through Trails and Rails), California State Railroad 

Museum, Train Host Association, and Native American Guides. All guides must 

present a valid form of photo identification, valid identification for the 

organization they are representing, and give a signed Form 3085 to either the 

Conductor or Assistant Conductor at the time of boarding. If the onboard guide 

does not have a Form NRPC 3085, the Conductor or Assistant must provide one 

and ensure that it is properly filled out and signed. The Conductor is responsible 

for placing the completed NRPC 3085(s) into the NRPC 158 Train Collections 

Pouch to provide a record of the individual’s presence on the train. The 

Conductor must also present the yellow copy of the Form NRPC 3085 to the 

agent at the next staffed station so that the manifest may be updated in Arrow in 

compliance with Items1.e and 1.f in this section. 

3. Documenting the Travel Using the Passenger On-Board Record 

a. A specimen of Form NRPC 3085 is reproduced below. Supplies of these forms 

are available at all crew base locations. 
107

b. These are one-part, unnumbered forms, bound in booklets of twenty-five (25). 

Conductor(s) and Assistant Conductor(s) must ensure that all of the required 

information is provided on the forms, and must punch the form upon completion 

in the lower right hand corner to certify the record. 

Specimen Form NRPC 3085 
108

c. The following is a list of Amtrak trains for which these procedures apply: 

Train Number Train Name 

1&2 Sunset Limited 

3&4 Southwest Chief 

5&6 California Zephyr 

7&8/27&28 Empire Builder 

11&14 Coast Starlight 

19&20 Crescent 

21&22 Texas Eagle 

29&30 Capitol Limited 

40&41 Three Rivers 

48&49/448&449 Lake Shore Limited 

50&51 Cardinal 

52&53 Auto Train 

58&59 City of New Orleans 

66&67 Federal 

89&90 Palmetto 

91&92 Silver Star 

97&98 Silver Meteor 

All Acela Express 

68&69/70&71 Empire Service 
109

Appendix C. Passenger Accountability Forms 

Figure 1. Form 3085 
110

 

Figure 2. Record of Tickets Honored but Not Lifted 
111

Figure 3. Onboard Ticket Sale Receipt 
112

Figure 4. Face of Ticket Pouch Envelope 
113

 

Figure 5. Ticket Pouch Instruction Flap 

115

Appendix D. Summary of NTSB Accident Reports and Briefs Related to 

Amtrak Accidents, 1993 to 2003 

Collision of Amtrak Train No. 90 and MARC Train No. 437, Baltimore, Maryland, 

June 17, 2002, NTSB Report Number RAB-03-01, adopted on 5/12/2003. 

Synopsis: At approximately 5:42 p.m., Eastern Standard Time, on June 17, 2002, northbound 

Amtrak train No. 90, The Palmetto, collided with southbound MARC train No. 437 in Baltimore, 

Maryland. Amtrak train No. 90 consisted of 2 locomotives and 11 cars (2 mail handlers, 4 

coaches, 1 dinette car, 1 baggage car, and 3 RoadRailers). The train had 141 passengers and 6 

crewmembers on board. MARC train No. 437 consisted of 1 locomotive and 7 cars. The train 

had 60 passengers and 4 crewmembers on board. The collision resulted in six minor injuries. 

The accident resulted in minor injuries to three MARC passengers, one MARC conductor, one 

Amtrak passenger, and one Amtrak conductor. All injured were treated and released. 

Type of Accident: Collision between on track equipment.

Accident Result: Lead truck of Amtrak locomotive derailed, two MARC cars derailed but 

remained upright.

Type of Train: The Palmetto is a reserved train. 

Type of Equipment: Did not have sleeper cars.

Time of day: 5:42 p.m.–daylight.

Crew Training: Not discussed in the NTSB report. 

Crew Incapacitated: One Amtrak conductor received minor injuries.

Bystanders Involved: Not discussed in the NTSB report. 

Timeliness of Emergency Response: Not discussed in the NTSB report. 

Training of Emergency Responders: Not discussed in the NTSB report. 

Number of Passengers and Crew: 141 passengers and 6 crewmembers.

Passenger and Crew Injuries: 1 Amtrak passenger and 1 crewmember received minor injuries. 

Cause of Death: Not applicable. 

Manifest Identified as Issue by NTSB: No. 
116

Other Issues Identified by NTSB: Engineer’s lack of familiarity with the equipment and lack 

of a positive train control system.

Likely Impact of Having a Manifest: None. In accidents in which cars have remained upright 

and in which minimal structural damage to the cars and no passenger ejection has occurred, little 

danger exists to first responders in searching the cars for all passengers, and little likelihood 

exists that passengers would be missed in a search of the cars. In this case, the first responders 

would be reasonably sure that they had not missed any passengers in their search efforts; while 

an accurate manifest would be nice to have, it would not be essential to their efforts. 
117

Derailment of Amtrak Auto Train on the CSXT Railroad near Crescent City, 

Florida, April 18, 2002, NTSB Report Number RAR-03-02, adopted on 8/5/2003. 

Synopsis: At approximately 5:08 p.m., Eastern Standard Time, on April 18, 2002, northbound 

National Railroad Passenger Corporation (Amtrak) train P052-18,2, the Auto Train, derailed 21 

of 40 cars on CSX Transportation (CSXT) track near Crescent City, Florida. The train was 

carrying 413 passengers and 33 Amtrak employees. Of the 33 Amtrak employees on the train, 

24 were service personnel, 5 were service managers, and 4 were train-operating crewmembers. 

The derailment resulted in 4 fatalities, 36 serious injuries, and 106 minor injuries. 

Type of Accident: Derailment. 

Accident Result: Of the 21 derailed cars, 8 ended up lying on their sides with the other derailed 

cars remaining in either an upright or leaning position.

Type of Train: The Auto Train is a reserved train. 

Type of Equipment: Did have sleeper cars. 

Time of day: 5:08 p.m.–dusk. 

Crew Training: With one exception, all crewmembers had received Amtrak’s Personnel 

Emergency Preparedness Training. Whether or not passengers had been briefed on emergency 

procedures upon departure is unknown. 

Crew Incapacitated: Amtrak employees on board sustained one serious and one minor injury. 

Bystanders Involved: Bystanders were not involved in evacuation or rescue efforts. 

Timeliness of Emergency Response: Emergency responders were notified immediately 

following the accident. However, they were not told the number of people on the train. The first 

police unit arrived within 6 minutes, the first fire unit within 9 minutes, and the first paramedics 

within 14 minutes. On scene incident command was established within 11 minutes, and triage 

and staging areas were established. 

Training of Emergency Responders: On September 19, 1997, an Amtrak emergency 

preparedness manager provided Passenger Train Emergency Response training to 63 members of 

various emergency response agencies in Putnam County. Personnel who received the Amtrak 

training and responded to the Crescent City derailment included the chief of the Crescent City 

Fire Department, who was the initial incident commander; the training coordinator for Putnam 

County Emergency Services, who was the final incident commander; and the Putnam County 

Sheriff’s Office communications captain. Amtrak subsequently provided similar training to 

emergency responders from the surrounding counties. 

Some emergency responders were already somewhat familiar with Amtrak equipment, because 

of a prior Amtrak accident in the area (December 17, 1991). 
118

Number of Passengers and Crew: 413 passengers and 33 crewmembers (24 service personnel, 

5 service managers, and 4 train-operating crewmembers).

Passenger and Crew Injuries: 4 passenger fatalities, 35 serious passenger injuries, 104 minor 

passenger injuries, 1 serious injury to an employee on board, and 1 minor injury to an employee 

on board.

Cause of Death: The four passengers were partially ejected through the car windows and 

crushed between the car body and track ballast.

Manifest Identified as Issue by NTSB: Yes. 

Other Issues Identified by NTSB: Track maintenance procedures and railcar crashworthiness. 

Likely Impact of Having a Manifest: None. The four fatally injured passengers were dead 

when found by emergency responders. No indication exists that emergency responders spent 

undue amounts of time searching for passengers or that emergency responders were in danger in 

searching the wreckage. Two hours after the accident, the incident commander reported that all 

passengers had been evacuated except for one entrapped fatality, even though he could not 

reconcile the greeter list and the passenger list, which indicated the location of passengers by car 

and room. 
119

Railroad Accident Brief: Derailment of Amtrak Train No. 5-17 on Burlington 

Northern and Santa Fe Railway Track near Nodaway, Iowa, March 17, 2001, 

NTSB Report Number RAB-02-01, adopted on 3/5/2002. 

Synopsis: On March 17, 2001, at approximately 11:40 p.m., Central Standard Time, westbound 

Amtrak train No. 5-17, the California Zephyr, derailed near Nodaway, Iowa. Amtrak train No. 

5-17 consisted of 2 locomotive units and 16 cars. All but the last five cars derailed. No fire or 

hazardous materials were involved in the accident. The train crew consisted of 1 engineer and 2 

conductors with 13 onboard service (OBS) personnel. In addition, 241 passengers were on the 

train. As a result of the derailment, 78 people were injured, including 1 fatal injury.

Type of Accident: Derailment. 

Accident Result: No indication as to whether derailed cars remained upright.

Type of Train: The California Zephyr is a reserved train. 

Type of Equipment: Not discussed in the NTSB report. 

Time of day: 11:40 p.m.–darkness.

Crew Training: Not discussed in the NTSB report. 

Crew Incapacitated: Not discussed in the NTSB report. 

Bystanders Involved: Not discussed in the NTSB report. 

Timeliness of Emergency Response: Not discussed in the NTSB report. 

Training of Emergency Responders: Not discussed in the NTSB report. 

Number of Passengers and Crew: 241 passengers and 16 crewmembers (13 service personnel 

and 3 train-operating crewmembers). 

Passenger and Crew Injuries: 78 people were injured, including 1 fatal injury.

Cause of Death: Not discussed in the NTSB report. 

Manifest Identified as Issue by NTSB: No. 

Other Issues Identified by NTSB: Track maintenance procedures. 

Likely Impact of Having a Manifest: Unknown. Accident circumstances not discussed in 

sufficient detail in the NTSB report. 
120

Railroad Accident Report: Rear-End Collision of National Railroad Passenger 

Corporation Train P286 with CSXT Freight Train Q620 on the CSX Railroad at 

Syracuse, New York, February 5, 2001, NTSB Report Number RAR-01-04, 

adopted on 11/27/2001. 

Synopsis: At approximately 11:40 a.m., Eastern Standard Time, on February 5, 2001, eastbound 

Amtrak train 286 with 100 passengers and 4 crewmembers struck the rear of eastbound CSXT 

freight train Q620 on the CSXT Railroad near Syracuse, New York. On impact, the lead Amtrak 

locomotive unit and four of the train’s five cars derailed. The rear truck of the last car of the 92-

car CSXT freight train derailed, and the car lost a portion of its load of lumber. At the time of 

impact, the passenger train was traveling 35 mph; the freight train was traveling 7 mph. The 

accident resulted in injuries to all 4 crewmembers and 58 of the passengers aboard the Amtrak 

train. No CSXT crewmember was injured. A small amount of diesel fuel spilled from the fuel 

tank on the lead Amtrak locomotive unit, but no fire resulted. 

Type of Accident: Collision between on track equipment.

Accident Result: All cars remained upright.

Type of Train: Train 286 was an Empire Service train and operated as a reserved train between 

Niagara Falls and Albany. 

Type of Equipment: Did not have sleeper cars. 

Time of day: 11:40 a.m.–daylight

Crew Training: Not discussed in the NTSB report. 

Crew Incapacitated: All crewmembers received minor injuries. 

Bystanders Involved: Bystanders were not involved in evacuation or rescue efforts. 

Timeliness of Emergency Response: Both train crews immediately notified the CSXT 

dispatcher after the collision, who immediately notified emergency responders that a train 

accident had occurred involving multiple injuries but no fire. However, they were not told the 

number of people on the train. The first fire units arrived within 15 minutes and set up an 

incident command post. The first medical units arrived within 32 minutes and established a 

triage area. Patients were evaluated, treated, and transported to local hospitals. The first patient 

left the scene 1 hour and 24 minutes after the accident, while the last of 44 people transported to 

a hospital left the scene 2 hours and 4 minutes after the accident. 
121

Training of Emergency Responders: No previous training had been done with regard to 

passenger trains with or without Amtrak or CSXT. Amtrak does provide passenger train 

equipment and locomotives, along with an instructor, to the New York State Association of Fire 

Chief’s annual conference, which is held in Syracuse. However, in May 2000, Onondaga 

County conducted a mass casualty exercise that simulated an airplane crash involving 43 

casualties plus 18 fatalities. 

Number of Passengers and Crew: 100 passengers and 4 crewmembers (1 service personnel 

and 3 train-operating crewmembers). 

Passenger and Crew Injuries: 4 serious passenger injuries, 54 minor passenger injuries, 3 

minor operating employee injuries, and 1 minor injury to an employee on board. 

Cause of Death: Not applicable. 

Manifest Identified as Issue by NTSB: No. 

Other Issues Identified by NTSB: The need to include rail mileposts on emergency 

responders’ maps, and the lack of a positive train control system 

Likely Impact of Having a Manifest: None. In accidents in which cars have remained upright 

and in which minimal structural damage to the cars and no passenger ejection has occurred, little 

danger exists to first responders in searching the cars for all passengers, and little likelihood 

exists that passengers would be missed in a search of the cars. In this case, the first responders 

would be reasonably sure that they had not missed any passengers in their search efforts; while 

an accurate manifest would be nice to have, it would not be essential to their efforts. 
122

Highway Accident Report: Report of Grade Crossing Accident Regarding a 

Collision between an Amtrak Train and a Tractor-Trailer Combination Vehicle 

Intercession City, Florida, November 17, 2000, NTSB Report Number HAR-02-

02, adopted on 7/23/2002. 

Synopsis: On November 17, 2000, at approximately 4:35 p.m., Eastern Standard Time, near 

Intercession City, Florida, a 23-axle, heavy-haul vehicle was delivering an 82-ton condenser to 

the Kissimmee Utility Authority (KUA) Cane Island Power Plant. The private access road to the 

electricity generating facility crossed over a single railroad track owned by CSXT. As the 

vehicle, traveling between 1 and 3 mph, crossed the tracks, the crossing warning devices 

activated, and the gates came down on the load. Seconds later, Amtrak train 97, operated by the 

National Railroad Passenger Corporation, collided with the right side of the rear towed four-axle 

tractor. Amtrak train 97 was traveling approximately 57 mph at the time of the collision. Two 

train crewmembers and three passengers were taken to area hospitals for observation; no injuries 

occurred. The Amtrak train was bound from New York City to Miami, Florida, with 83 

passengers and 4 crewmembers on board. 

Type of Accident: Highway-rail collision/impact.

Accident Result: The locomotive and all train cars remained upright.

Type of Train: Train 97, the Silver Meteor is a reserved train. 

Type of Equipment: Did have sleeper cars.

Time of day: 4:35 p.m.–dusk 

Crew Training: Not discussed in the NTSB report. 

Crew Incapacitated: No.

Bystanders Involved: No. 

Timeliness of Emergency Response: The engineer of the train initiated the standard emergency 

tone-9 radio procedure to contact the CSXT train dispatcher after the train came to a stop. The 

train dispatcher contacted the CSXT Police Communications Center, which contacted the local 

emergency services without delay. The first law enforcement officer arrived within 12 minutes, 

and 3 fire department vehicles and the first ambulance arrived within 15 minutes. The fire 

department dispatched three fire engines, seven ambulances, two hazardous materials specialty 

units, five staff/supervisors, and two service vehicles (one with portable light towers and one 

food service truck). Two emergency medical technicians boarded the locomotive and examined 

the engineer and assistant engineer. Emergency medical technicians also searched the train cars 

for injured passengers. One passenger fell as the train passengers were being evacuated and was 

transported to an area hospital. 
123

Training of Emergency Responders: The Osceola County Fire Chief stated that his 

department had a railway plan that specifically addressed railway transportation accidents. He 

further indicated that the response plan was written in the early 1990s and had not been updated. 

Number of Passengers and Crew: 83 passengers and 4 operating crewmembers. 

Passenger and Crew Injuries: No reportable injuries to passengers or crew.

Cause of Death: Not applicable. 

Manifest Identified as Issue by NTSB: No. 

Other Issues Identified by NTSB: Improved procedures to ensure that railroads are notified 

that oversized, slow-moving vehicles will be crossing their tracks. 

Likely Impact of Having a Manifest: None. In accidents in which cars have remained upright 

and in which minimal structural damage to the cars and no passenger ejection has occurred, little 

danger exists to first responders in searching the cars for all passengers, and little likelihood 

exists that passengers would be missed in a search of the cars. In this case, the first responders 

would be reasonably sure that they had not missed any passengers in their search efforts; while 

an accurate manifest would be nice to have, it would not be essential to their efforts. 
124

Railroad Accident Report: Collision of Amtrak Train 304-26 with a Highway 

Vehicle at a Highway-Rail Grade Crossing in McLean, Illinois, on September 26, 

1999, NTSB Report Number RAR-01-03. 

Synopsis: On September 26, 1999, at approximately 5:08 p.m., northbound National Railroad 

Passenger Corporation (Amtrak) train 304-26, which was en route from St. Louis, Missouri, to 

Chicago, Illinois, collided with an automobile, which was westbound on U.S. Route 136. The 

collision occurred at the highway-rail grade crossing (DOT #290 964A) where the Union Pacific 

Railroad’s (UP) St. Louis Division main line and U.S. Route 136 cross near McLean, Illinois. 

The automobile driver and passenger were killed as a result of the collision. Amtrak train 304-

26 did not derail, and no injuries to the train crewmembers or passengers were reported. 

Type of Accident: Highway-rail collision/impact.

Accident Result: The locomotive and all train cars remained upright on the rail.

Type of Train: Train 304, the Ann Rutledge is a reserved train. 

Type of Equipment: Did not have sleeper cars. 

Time of day: 5:08 p.m.–dusk. 

Crew Training: Not discussed in the NTSB report. 

Crew Incapacitated: No. 

Bystanders Involved: No. 

Timeliness of Emergency Response: When the train came to a stop, the Amtrak conductor, 

who was in the lead coach car with the assistant conductor, walked through the train advising 

and instructing the passengers. He then detrained through the rear coach car and observed the 

wreckage. He placed an emergency 911 call using a cellular telephone. According to the 

engineer and the conductor, emergency medical services personnel responded within minutes of 

the call. Additionally, a physician who was onboard the train at the time offered his services at 

the scene. 

Training of Emergency Responders: Not discussed in the NTSB report. 

Number of Passengers and Crew: Three operating crewmembers, the number of passengers 

was not indicated by NTSB. 

Passenger and Crew Injuries: None reported.

Cause of Death: Not applicable. 
125

Manifest Identified as Issue by NTSB: No. 

Other Issues Identified by NTSB: Improper grade crossing signal maintenance procedures. 

Likely Impact of Having a Manifest: None. In accidents in which cars have remained upright 

and in which minimal structural damage to the cars and no passenger ejection has occurred, little 

danger exists to first responders in searching the cars for all passengers, and little likelihood 

exists that passengers would be missed in a search of the cars. In this case, the first responders 

would be reasonably sure that they had not missed any passengers in their search efforts; while 

an accurate manifest would be nice to have, it would not be essential to their efforts. 
126

Collision of National Railroad Passenger Corporation Train 59 with a Loaded 

Truck-Semitrailer Combination at a Highway-Rail Grade Crossing in 

Bourbonnais, Illinois, March 15, 1999, NTSB Report Number RAR-02-01, 

adopted on 2/5/2002. 

Synopsis: At approximately 9:47 p.m. on March 15, 1999, National Railroad Passenger 

Corporation (Amtrak) train 59, with 207 passengers and 21 Amtrak or other railroad employees 

on board and operating on Illinois Central Railroad (IC) main line tracks, struck and destroyed 

the loaded trailer of a tractor-semitrailer combination that was traversing the McKnight Road 

grade crossing in Bourbonnais, Illinois. Both locomotives and 11 of the 14 cars in the Amtrak 

consist derailed. The derailed Amtrak cars struck 2 of 10 freight cars that were standing on an 

adjacent siding. The accident resulted in 11 deaths and 122 people being transported to local 

hospitals. 

 

Type of Accident: Highway-rail collision/impact. 

Accident Result: One of the cars rolled over onto its side. Another car, although upright, was 

bent around the back of a locomotive, and portions of the car were engulfed by fire from spilt 

fuel. 

Type of Train: Train 59, the City of New Orleans is a reserved train. 

Type of Equipment: Did have sleeper cars.

Time of day: 9:47 p.m.–darkness. 

Crew Training: Not discussed in the NTSB report. 

Crew Incapacitated: 5 crewmembers sustained serious injuries, 4 minor injuries, and 12 were 

uninjured. 

Bystanders Involved: When the first Bourbonnais Fire Protection District personnel arrived at 

the accident scene, they saw that some 30 to 35 employees of Birmingham Steel had responded 

to the scene and had begun the rescue effort. These steel plant employees had cut a hole in the 

chain-link fence separating the wreckage site from the steel plant’s property and brought a 

number of handheld fire extinguishers and ladders from the plant to combat the flames. While 

some of the steel plant employees applied the fire extinguishers to the flames, others entered 

some of the damaged passenger cars to extricate entrapped passengers. These efforts were 

continued for approximately 45 minutes, when Bourbonnais Fire Protection District personnel, 

who continued the extrication efforts, relieved the steel plant employees. 

Timeliness of Emergency Response: The time of the accident was at approximately 9:47 p.m. 

The conductor stated that he was walking through the coach behind the diner when he heard the 

train’s brakes apply and felt a bump. He believed that the train accelerated, and then the car 

rolled over on its side. The conductor stated that at this point, he helped a passenger remove a 
127

window and climbed outside; once outside, he communicated by radio with the assistant 

conductor and the locomotive engineer. When the engineer said that he was trapped in the 

locomotive, the assistant conductor said he would go help the engineer. The conductor remained 

at the coach and helped passengers evacuate. 

At 9:48 p.m., the Kankakee County Sheriff’s Police 911 communications desk received the 

initial request for emergency assistance via telephone from the Birmingham Steel security office. 

Shortly thereafter, a second call came from the Birmingham Steel Company; this was followed 

by a number of additional calls from various sources. The first police units arrived on scene 

within 3 minutes and began helping to evacuate the passenger cars. Within a short time, more 

police units responded, and officers began evacuating passengers wherever they could. The 

Bourbonnais Police Department established an initial staging area on the unpaved roadway on 

the west side of the tracks, in the area adjacent to the wreckage pileup. The evacuated 

passengers and traincrew assembled in this area, where responding ambulances later arrived. 

The first ambulances arrived at the scene within 6 minutes and the first fire units within 12 

minutes. A fire department field command post was established at the initial staging area. 

In interviews with NTSB, emergency responders indicated that the immediate focus of the 

response was the extrication of the trapped and injured passengers and traincrew. Because the 

derailed train cars blocked McKnight Road at the grade crossing, three separate staging areas 

were established. Upon evacuation, displaced passengers and traincrew were taken to one of two 

triage areas initially established at the scene. Because the temperature that night was estimated 

to be in the low 20s, the incident commander became concerned about the threat of hypothermia, 

since most of the evacuees lacked warm clothing. A local retail store offered its facility as a 

temporary shelter; starting at approximately 10:28 p.m., responders used this facility as a shelter 

and a triage site for several persons who were later found to have sustained injuries. 

Approximately 50 minutes after the accident, a medical trauma team consisting of physicians and 

medical equipment from local hospitals arrived at the scene. About this time, police officers 

were extricating passengers through the emergency exit windows of an overturned coach car 

(No. 34089) that lay on the eastern side of the pileup. 

A Braidwood Fire Department officer, who arrived approximately 50 minutes after the first 

emergency responder, was familiar with petrochemical fires and recognized almost immediately 

that a large amount of foam was necessary to combat the blaze. Upon receiving concurrence 

from the incident commander, he called for heavy foam tanker trucks to come from a local 

chemical plant. The foam tanker arrived and was set up about 1 hour later. Within a few 

minutes of this equipment applying foam, the fire was extinguished. Before the Braidwood 

officer arrived, the incident commander had directed firefighting operations that had proved 

ineffective at either extinguishing the flames or at keeping the fire away from the sleeper car in 

which occupants were entrapped. 

At approximately 12:05 a.m. on March 16, an emergency shelter established at a nearby school 

building began to receive the uninjured displaced passengers who were transferred from the 

temporary shelter established earlier at the retail store. 
128

Training of Emergency Responders: Upon request, Amtrak provides an instructional 

information/training program for those local agencies most likely to respond to an Amtrak 

emergency. Without this training, local emergency responders may not know how to gain access 

to an overturned locomotive or passenger car, may not know where in cars to search for trapped 

occupants, and may not be aware of the quantities of diesel fuel available to fuel a fire. Before 

this accident, neither the Bourbonnais Fire Protection District nor other Kankakee County 

emergency responders had been provided onsite instruction or training in responding to such 

emergencies. 

Number of Passengers and Crew: 207 passengers, 17 Amtrak crewmembers, and 4 off-duty 

Amtrak and IC railroad employees. 

Passenger and Crew Injuries: 11 passenger fatalities, 34 serious passenger injuries, 55 minor 

passenger injuries, 5 serious crewmember injuries, and 4 minor crewmember injuries. 

Cause of Death: Eleven train passengers, all of who were located in sleeper car 32035, which 

was bent around the back of the locomotive, sustained fatal injuries. The fatally injured 

occupants were in the portions of the car at the vertex of the car’s bend, where the crush and 

intrusion were at a maximum. This portion of the car was also later consumed by fire. The 

coroner tentatively attributed 5 of the 11 deaths of the fatally injured occupants to the effects of 

the fire. The coroner was unable to determine whether any of these five might have succumbed 

to their traumatic injuries had they not been exposed to the fire. The other six fatalities 

apparently resulted from their traumatic injuries. 

Manifest Identified as Issue by NTSB: Yes. 

Other Issues Identified by NTSB: Because of insufficient training in responding to railroad 

emergencies or inadequate/inappropriate resources, or both, the emergency responders were not 

prepared to respond effectively to a passenger train accident involving a significant diesel fuel 

fire. 

Likely Impact of Having a Manifest: None. In accidents involving fire, the need for 

immediate passenger evacuation supersedes the need for passenger accountability. This, 

combined with the fact that counting evacuated passengers takes hours, minimizes the value of 

having an accurate manifest readily available. 

Six of the passengers apparently died as a result of the crash, before the outbreak of the fire. The 

other five passengers died as a result of the fire, which was not brought under control until nearly 

2 hours after the accident. The establishment of three separate outdoor staging areas, followed 

by the establishment of a temporary indoor shelter and then a second emergency shelter, would 

have complicated the task of completing an accurate census of the injured and uninjured 

passengers in a timely fashion. At that point, knowing that 11 passengers were unaccounted for 

and in the burning sleeping car would have done little to ensure their survival. 
129

Railroad Accident Report: Derailment of Amtrak Train 21 on the Union Pacific 

Railroad at Arlington, Texas, December 20, 1998, NTSB Report Number RAR-01-

02, adopted on 7/24/2001. 

Synopsis: At approximately 7:00 p.m., Central Standard Time, on December 20, 1998, National 

Railroad Passenger Corporation (Amtrak) train No. 21, the Texas Eagle, derailed on UP tracks in 

Arlington, Texas. The train was traveling westbound at a reduced speed of about 36 mph due to 

reports of rough track near milepost (MP) 231. Three locomotives and six cars derailed in a 

curve at MP 230.62. Of the 198 passengers and 18 employees on the train, 12 passengers and 10 

employees were injured. No fatalities resulted from the accident. 

 

Type of Accident: Derailment. 

Accident Result: All 3 locomotives and 6 of the 10 cars derailed. The lead and second 

locomotives remained upright and aligned with the track. The third locomotive and the first four 

cars turned at different angles to the track and rolled onto their sides. The fifth and sixth cars 

derailed but remained upright and essentially aligned with the track. 

Type of Train: Train 21, the Texas Eagle is a reserved train. 

Type of Equipment: Did have sleeper cars. 

Time of day: 7:00 p.m.–darkness. 

Crew Training: Not discussed in the NTSB report. 

Crew Incapacitated: 10 crewmembers sustained minor injuries. 

Bystanders Involved: No. 

Timeliness of Emergency Response: At 7:02 p.m. (2 minutes after the accident), an unknown 

caller told the Arlington emergency operator about the derailed train. Numerous additional calls 

followed to report the accident. The Arlington Fire Department responded with 13 engine 

companies (pumping trucks), 1 aerial platform truck, 3 truck companies, and 2 additional 

support/utility vehicles. 

According to the Arlington Fire Department battalion chief, when the firefighters crossed the 

drainage ditch with rescued train occupants, they had to maneuver through passenger cars that 

were lying on their sides. None of the people on board the train had been trapped in the 

wreckage. Passengers in cars that were essentially upright were able to leave immediately and 

directly through open passageways and doors. In cars that were not upright, some passengers 

were unable to leave directly through open passageways (open doors or emergency windows) 

and were extricated by means of ladders, which firefighters put through opened emergency exit 

windows. 
130

Training of Emergency Responders: Not discussed in the NTSB report. 

Number of Passengers and Crew: 198 passengers, 6 operating crewmembers, and 12 OBS 

crewmembers. 

Passenger and Crew Injuries: 12 passengers and 10 crewmembers sustained minor injuries; 8 

crewmembers and 186 passengers sustained no injury. 

The NTSB report notes: 

The number of documented medical transports by the municipal ambulance 

service differs from the total treated at medical facilities because several family 

members accompanying patients were later evaluated by hospital personnel, and 

several persons were transported to the hospital by private automobile, rather than 

being transported by the municipal ambulance service.

Cause of Death: Not applicable. 

Manifest Identified as Issue by NTSB: No. 

Other Issues Identified by NTSB: Inadequate procedures for responding to reports of track 

problems, oversight of track maintenance and communicating changes in track classification. 

Likely Impact of Having a Manifest: None. In accidents in which cars have overturned and 

suffered structural damage, a possibility for passenger ejection and/or entrapment exists. In this 

case, passenger ejection/entrapment was not an issue. The potential safety benefits of having an 

accurate manifest in terms of improving passenger survivability are minimized by the fact that 

counting evacuated passengers takes hours under controlled circumstances. As indicated above 

in Passenger and Crew Injuries, some passengers apparently proceeded to hospitals on their own 

and were not accounted for by first responders on the scene. 
131

Collision of Northern Indiana Commuter Transportation District Train 102 with a 

Tractor-Trailer Portage, Indiana June 18,1998, NTSB Report Number: RAR-99-

03, adopted on 7/26/1999. 

Synopsis: At approximately 4:31 a.m., Central Standard Time, on Thursday, June 18, 1998, 

Northern Indiana Commuter Transportation District (NICTD) train 102, a two-car passenger 

train, collided with the right side of a long combination vehicle (LCV) at the Midwest Division 

of the National Steel Corporation’s (Midwest Steel) grade crossing near Portage, Indiana. At this 

grade crossing, a private road leads north from U.S. Route 12 (US 12), intersects NICTD and 

Consolidated Rail Corporation (Conrail) railroad tracks, and continues to the Midwest Steel 

facility and other businesses. The collision occurred on the westward NICTD track. 

Shortly before the collision, while the LCV was traversing the NICTD tracks, the approach of 

the westbound Conrail train 201 had activated the flashing light signals and automatic gates at 

the Conrail crossing. The truck driver stopped the LCV before the Conrail crossing’s south gate. 

The vehicle’s second semitrailer was resting on the westward NICTD track. At this time, 

NICTD train 102 traveling westbound about 68 mph was approaching the Midwest Steel grade 

crossing. 

About 542 feet east of the crossing, the train 102 crew noticed the LCV’s second semitrailer, 

which carried a steel coil (weighing about 19 tons), on the crossing. The engineer said that he 

placed the train in emergency braking; followed by the conductor, he then exited the control 

compartment and ran toward the rear of the passenger compartment. The crew alerted 

passengers in that area about the impending collision and told them to evacuate. 

As the collision occurred, the LCV’s second semitrailer broke away from the first semitrailer and 

was dragged by the front of the NICTD train, while the single chain securing a steel coil to the 

second semitrailer broke. The released steel coil entered the lead car of the train through the 

front bulkhead. The coil moved through the car until it came to rest about 34 feet into the 

passenger compartment. Three fatalities and five minor injuries among the passengers resulted.

Type of Accident: Highway-rail collision/impact. 

Accident Result: The cars remained coupled during the accident, and neither car derailed. No 

fire occurred in either car. 

Type of Train: Commuter Rail. 

Type of Equipment: Did not have sleeper cars. 

Time of day: 4:31 a.m.–dawn. 

Crew Training: Not discussed in the NTSB report. 

Crew Incapacitated: No. 
132

Bystanders Involved: No. 

Timeliness of Emergency Response: After the impact with the LCV, the engineer moved to the 

operating cab in the rear of the second car and radioed the dispatcher to inform him, “we had hit 

a truck at the Midwest rail crossing and for him to get emergency personnel out as quickly as 

possible.” The engineer said he then returned to the first car to attempt to help the injured 

passengers. On the way, he met the conductor, who was going to the second car. The engineer 

took the conductor’s flashlight and continued into the first car, where he saw the injured NICTD 

employee. He went back to the second car and called the dispatcher again to let him know that 

the conductor was safe. He also advised the dispatcher that the coil had come into the car. 

A Midwest Steel representative notified the Portage Police Department (PPD) dispatcher of the 

accident at 4:35 a.m. The PPD dispatcher dispatched Portage police, fire, and emergency 

medical services personnel at 4:36 a.m. The emergency response personnel arrived at the 

accident site within about 10 minutes. The 13 remaining passengers and 2 members of the crew 

exited through the last door on the south side of the second car. By the time they had exited the 

train, emergency personnel (police) were arriving, and the engineer told them where to find the 

injured passengers. 

The fire chief established incident and medical command and became the incident commander. 

At this time, the incident commander was advised that three people were inside the first NICTD 

car; two were dead, and one was alive but severely injured and pinned under the steel coil. The 

PFD chief immediately requested a crane from Midwest Steel to raise the coil. The assistant 

PFD chief asked the PPD dispatcher to request a University of Chicago Aeromedical Network 

helicopter and additional assistance. The assistant chief also contacted the Methodist Hospital, 

Northlake campus, to request a surgeon. While the additional help was being sought, a 

paramedic firefighter tried to communicate with, administer oxygen to, and monitor the cardiac 

status of the severely injured person pinned under the coil. About 10 minutes later, the incident 

commander was told that the injured person had lost all vital signs. 

Training of Emergency Responders: Not discussed in the NTSB report. 

Number of Passengers and Crew: 15 passengers, 2 crewmembers, and 1 deadheading railroad 

employee. 

Passenger and Crew Injuries: One railroad employee and 2 passengers sustained fatal injuries, 

5 passengers sustained minor injuries, and 2 crewmembers and 8 passengers sustained no injury. 

Cause of Death: Crushed by 19 ton steel coil. 

Manifest Identified as Issue by NTSB: No. 

Other Issues Identified by NTSB: Safety of private grade crossings, and crashworthiness of 

the rail cars. 
133

Likely Impact of Having a Manifest: None. Despite timely response by emergency 

responders, despite the fact that all passengers and crew were accounted for, and despite the fact 

that emergency responders were told the exact location of the entrapped victim, he died shortly 

after the arrival of the emergency responders due to the nature of his injuries. 
134

Grade Crossing Collision, National Railroad Passenger Corporation with Coastal 

Transport Tractor-Semitrailer, Jacksonville, Florida, February 5, 1997, NTSB 

Report Number RAB-01-01, adopted on 10/26/2000.

Synopsis: At approximately 4:45 p.m., Eastern Standard Time, on February 5, 1997, National 

Railroad Passenger Corporation (Amtrak) train P098, the Silver Meteor, while operating over 

CSXT tracks, struck a tractor-semitrailer combination at Old Kings Road in Jacksonville, 

Florida. The locomotive and four leading cars derailed. Of the 182 passengers and crew 

onboard the train, 15 reported injuries. The injured passengers were treated and released the 

same day. The locomotive engineer and assistant engineer were hospitalized and released after 

48 hours with minor injuries. The tractor-semitrailer was destroyed. The truck driver had exited 

the truck before the collision and was not injured. 

Amtrak train P098, with one locomotive, one baggage car, and nine passenger cars, originated in 

Miami on the day of the accident. Approaching Old Kings Road at MP 631.8 on the CSXT 

Nahunta Subdivision, the engine crew observed that the crossing gates were down and that a 

truck was on the track. When he realized that the truck was not moving, the engineer applied the 

train’s emergency brakes. The collision caused the locomotive and the first four cars to derail. 

The locomotive and baggage car came to rest on their sides. All derailed passenger cars 

remained upright. The train crew organized an evacuation of passengers, which was 

accomplished without incident. Police and emergency medical personnel arrived on scene 

shortly after the accident.

Type of Accident: Highway-rail collision/impact. 

Accident Result: The collision caused the locomotive and the first four cars to derail. The 

locomotive and baggage cars came to rest on their sides. All derailed passenger cars remained 

upright. 

Type of Train: The Silver Meteor is a reserved train. 

Type of Equipment: Did have sleeper cars. 

Time of day: 4:45 p.m.–dusk. 

Crew Training: Not discussed in the NTSB report. 

Crew Incapacitated: Engineer and assistant engineer sustained minor injuries.

Bystanders Involved: No. 

Timeliness of Emergency Response: Police and emergency medical personnel arrived on scene 

shortly after the accident.

Training of Emergency Responders: Not discussed in the NTSB report. 
135

Number of Passengers and Crew: 182 passengers and crew. 

Passenger and Crew Injuries: 2 crewmembers and 13 passengers sustained minor injuries. 

Cause of Death: Not applicable. 

Manifest Identified as Issue by NTSB: No. 

Other Issues Identified by NTSB: Failure of the truck driver to warn authorities that his 

vehicle was fouling the tracks. 

Likely Impact of Having a Manifest: None. In accidents in which cars have remained upright 

and in which minimal structural damage to the cars and no passenger ejection has occurred, little 

danger exists to first responders in searching the cars for all passengers, and little likelihood 

exists that passengers would be missed in a search of the cars. In this case, the first responders 

would be reasonably sure that they had not missed any passengers in their search efforts; while 

an accurate manifest would be nice to have, it would not be essential to their efforts. 
136

Railroad Accident Report Derailment of Amtrak Train 4, Southwest Chief, on the 

Burlington Northern Santa Fe Railway near Kingman, Arizona, August 9, 1997 

(Revision August 7, 2003), NTSB Report Number RAR-98-03, adopted on 

8/31/1998.

Synopsis: At approximately 5:56 a.m. on August 9, 1997, Amtrak train 4, the Southwest Chief, 

derailed on the Burlington Northern Santa Fe Railway (BNSF) tracks about 5 miles northeast of 

Kingman, Arizona. The train was traveling about 89 mph on the eastbound track when the 

engineer and assistant engineer saw a hump in the track as they approached bridge 504.1S. They 

stated that they applied the train’s emergency brakes. It was later discovered that the ground 

under the bridge supporting structure had washed away during a flash flood. 

Train 4 had a four-unit locomotive, one baggage car, nine passenger cars, and six material 

handling cars (MHCs). As the train passed over bridge 504.1S, the first three locomotive units 

uncoupled and separated from the rest of the train and each other, each unit coming to a stop east 

of the derailed train. The fourth unit remained coupled to the train. 

The third and fourth units, including all but the last car, derailed in the upright position. 

Although some cars were at a slight angle to each other and leaning, all cars remained coupled 

and generally aligned with the track. The tenth car, a sleeping car, came to rest spanning what 

had been the track at the location of bridge 504.1S.

Type of Accident: Derailment. 

Accident Result: The train came to rest with the last passenger car, sleeping car 32088, 

bridging the gap of the collapsed bridge 504.1S. The last locomotive unit and the rest of the cars 

remained coupled. The three locomotive units that uncoupled from the train came to rest with 

the lead locomotive unit about a mile beyond the rest of the train. All but the first two 

locomotive units and the last car derailed. All cars derailed upright with the passenger cars at 

shallow angles to each other. 

Type of Train: Train 4, Southwest Chief, is a reserved train. 

Type of Equipment: Did have sleeper cars. 

Time of day: 5:56 a.m.–dawn. 

Crew Training: Although passengers were safely evacuated, statements from the onboard 

service (OBS) personnel and a review of their training records indicated that the reactions of 

several of them were based on instinct rather than organized emergency training. NTSB 

reviewed Amtrak’s emergency situation training records for the 18 OBS persons and operating 

crewmembers involved in this accident. The training time intervals recorded varied between 

employees. The most recent training that could be identified from the employee records ranged 

from training taken 2 months before the accident to training taken as much as 7 years before the 

accident. Eight employees did not have any emergency situation training dates listed in their 
137

training records. These findings are inconsistent with Amtrak’s stated policy of scheduling 

emergency situation training at least every 3 years for OBS attendants. 

Train 4’s OBS personnel did not use the public address system to communicate evacuation 

information to the passengers. Although some crewmembers believed that the public address 

system did not work, they did not attempt to use it even though Amtrak’s emergency training 

procedures, as provided in the Amtrak training manual, call for its use in emergency situations. 

Wreckage documentation showed that the public address system was inoperable in some of the 

cars because of the damage sustained by the equipment. 

Crew Incapacitated: Of the crew, 1 sustained serious injuries, 9 minor injuries, and 8 no 

injuries. 

Bystanders Involved: No. 

Timeliness of Emergency Response: At approximately 5:56 a.m., the BNSF Network 

Operations (NOC) received a radio communication from the engineer of Amtrak train 4 

informing it of the train’s derailment and its location. NOC passed the information on to its 

Resource Operations Center and a BNSF special agent, who notified the Mohave County 

Sheriff’s Department at 6:01 a.m. Also about 5:56 a.m., the Mohave County Sheriff’s 

Department received a 911 call from a local resident reporting a train derailment. Three officers, 

who were already in the immediate area (searching for people who were reportedly stranded 

because of flash flooding), were dispatched to the scene and arrived at 6:05 a.m. Later, a 

Mohave County Sheriff’s Department lieutenant arrived on scene and assumed the duties of 

incident commander. They helped the Kingman Fire Department and emergency services 

personnel transport passengers and crew to triage areas, searched for train occupants, and 

secured the scene. They reported that no life-threatening injuries were noted. 

The first medical, rescue, and fire units arrived within 20 minutes of the accident. About 5 

minutes later, the first of three Arizona Department of Public Safety helicopters arrived on scene. 

Two military helicopters from Nellis Air Force Base arrived on scene later with a flight surgeon 

and medical crew. At 6:30 a.m. (35 minutes after the accident), a medical command post was set 

up next to the treatment and triage area. School buses were used to transport people with minor 

to moderate (or no) injuries to the local hospital and Kingman Junior High School, which was 

used as a shelter for passengers and crew. 

Approximately 1 hour after the accident, injured people began arriving at the hospital by 

helicopters, ambulances, and buses. By 8:00 a.m., about 230 people had been transported from 

the scene. BNSF personnel, emergency medical services personnel, and some passengers helped 

throughout the response. Shortly after 9:00 a.m., the last person was transported from the scene. 

The last person was admitted to the hospital at 11:00 a.m. 

Training of Emergency Responders: Before the accident, on November 15, 1996, Clark 

County, Nevada, and Mohave County, Arizona, held a joint full-scale exercise. 
138

On April 29, April 30, and May 1, 1997, a Festival of the Emergency Arts was held in Glendale, 

Arizona. At this festival, Amtrak’s manager of Emergency Preparedness addressed emergency 

responders about considerations that might affect emergency response procedures involving 

Amtrak train emergencies, such as railroad operations, equipment familiarization, passenger car 

construction, railroad right-of-way (ROW) safety precautions, passenger evacuation, forcible 

entry, locomotive propulsion systems, train crew orientations, electrical and pneumatic hazards, 

onboard emergency equipment, use of emergency exit doors and windows, hazardous materials, 

tunnels and bridges, grade crossing accidents, search and rescue, fire suppression, derailments, 

and other types of incidents. 

Although a state representative invited Kingman fire and rescue personnel, the festival 

attendance sheet did not indicate that anyone from Kingman had attended this training. No 

evidence was found of the Mohave County Sheriff’s Department being invited to or attending the 

festival. 

Number of Passengers and Crew: 294 passengers and 18 crewmembers. 

Passenger and Crew Injuries: Of the crew, 1 sustained serious injuries, 9 minor injuries, and 8 

no injuries, while 24 passengers sustained serious injuries, 149 minor injuries, and 121 no 

injuries. While the NTSB reports no fatalities, the FRA casualty and accident databases attribute 

one fatality to this accident.

Cause of Death: The fatality in the FRA data apparently resulted at a later date from injuries 

incurred during the accident. The victim was not entrapped but apparently injured when thrown 

from his/her seat during the derailment. 

Manifest Identified as Issue by NTSB: Yes. According to the conductor and one assistant 

conductor, at the time of this accident, they were in the dining car working on tickets. The 

conductor said that he did not have time to look at the manifest because it was in the dormitory 

car. He also stated that the manifest contained the number of passengers in coach sections and a 

complete list of passengers in the sleeping cars. The conductor said that the manifest should 

have been up-to-date except for tickets taken at Kingman. 

During the emergency response to the Kingman accident, the incident commander requested a 

copy of the train 4 manifest from an Amtrak employee. The conductor told NTSB investigators 

that a passenger manifest was located in the dormitory car, but he did not have time to obtain it 

because he was helping passengers. The chief of on board services said that he gave a copy of a 

sleeping car manifest to a firefighter. It took several days for Amtrak to provide an accurate 

passenger count of the entire train. 

A complete manifest is necessary, in addition to the counts provided by the conductor for the 

emergency responders to locate people on the train as quickly as possible and be alerted about 

those people who may need immediate assistance because of injuries or disabilities. Although a 

complete manifest of train 4 was eventually available, infants and small children were not 

included on it because Amtrak does not require tickets for infants and small children. 
139

Other Issues Identified by NTSB: Bridge inspection procedures and risk assessment, on board 

emergency lighting, crew emergency training, inaccuracies in the accident reporting process. 

Likely Impact of Having a Manifest: None. According to the NTSB report: 

Although no complete manifest was available during the emergency response in this instance, the 

lack of one did not appear to negatively affect the efficiency of the emergency response. 
140

Railroad Special Investigation Report Derailment of Amtrak Train No. 12 and 

Sideswipe of Amtrak Train No. 79 on Portal Bridge near Secaucus, New Jersey, 

November 23, 1996, NTSB Report Number SIR-97-01, adopted on 12/18/1997. 

Synopsis: At approximately 6:28 a.m. on Saturday, November 23, 1996, eastbound Amtrak 

train No. 12 derailed while crossing Portal Bridge, a swing bridge spanning the Hackensack 

River in Secaucus, New Jersey. When the train derailed, it sideswiped Amtrak train No. 79, 

which was crossing the bridge in the opposite direction on an adjacent track. All 12 cars of train 

No. 12 derailed, with both locomotives, 1 material handling car, and the 3 lead passenger 

coaches coming to rest at the bottom of an embankment at the east end of the bridge. Train No. 

79 sustained damage but was able to stop with the entire train intact and on the rails some 

distance west of Portal Bridge. No fatalities resulted from the accident, but 42 passengers and 

crewmembers aboard train No. 12 were injured, as was 1 passenger aboard train No. 79. 

Type of Accident: Derailment. 

Accident Result: Train No. 79 sustained sideswipe damage but stopped with the entire train 

intact and on the rails. Train No. 12 came to rest with both locomotives, one material handling 

car, and the first three passenger coaches entirely derailed, but upright and tilted in various 

positions down the embankment at the east end of the bridge. The remaining eight cars of train 

No. 12 remained upright and in line, but they were either totally or partially derailed. 

Type of Train: Train 79, the Carolinian, is unreserved north of Washington, DC. Train 12 is 

unknown. 

Type of Equipment: Neither train had sleeper cars. 

Time of day: 6:28 a.m.–dawn.

Crew Training: Not discussed in the NTSB report.

Crew Incapacitated: Two crewmembers on train No. 12 sustained minor injuries. 

Bystanders Involved: No. 

Timeliness of Emergency Response: According to telephone tape transcriptions, at 

approximately 6:36 a.m. (8 minutes after the accident) Amtrak’s assistant chief train dispatcher 

notified Amtrak’s National Police Dispatching Center (NPDC) in Philadelphia that train No. 12 

had derailed on Portal Bridge over the Hackensack River. The train dispatcher stated that police 

and emergency personnel would be needed at the scene. 

Emergency response to the accident was delayed because of confusion about the accident 

location. The problem can be traced to the Amtrak police dispatcher who called the appropriate 

agency, the Secaucus Police Department, but relayed the accident location as Portal Tunnel 
141

instead of Portal Bridge. The dispatcher further confused the issue when he called the North 

Bergen Police Department and reported the accident location as Portal Tunnel Bridge. 

Amtrak’s computerized geographical database indicated that the derailment fell within the 

Secaucus police area. The database also provided the closest access roads. Even with the 

confusion about the specific accident site, the location of the two nearby roads should have 

provided enough information to allow either the Secaucus police or the North Bergen police to 

determine the most likely accident location. This, however, did not occur. One reason may have 

been that the Secaucus police were apparently unaware that a Portal Bridge was located within 

their jurisdiction. It was only when a construction worker flagged down a Secaucus police 

cruiser that had been sent out to investigate and check known bridges in the area that the actual 

accident location became known. 

Shortly after the initial identification of the accident location, the Secaucus police called NPDC 

and said that the Secaucus police had located the accident site. The caller told NPDC how access 

had been gained to the site and provided a preliminary assessment of injuries. About 18 minutes 

elapsed between the time the NPDC was notified of the accident and the time the first police 

officers arrived on the scene. The first ambulance arrived on the scene about 47 minutes after 

the initial notification. 

Once at the bridge location, emergency responders had difficulty accessing the actual accident 

site. Some of the emergency vehicles approached the bridge from the west, but because the 

wreckage was on the east end of the bridge, they had to be rerouted to the other side. 

The first police officer on the scene saw that many, if not most, of the passengers had gotten off 

the train, and he was told that one person was still on the train being treated by train personnel. 

Training of Emergency Responders: Full-scale disaster drills and simulated tabletop exercises 

(without the use of train equipment or mock evacuations) are regularly held in Hudson County 

and all of its municipalities. Before this accident, the most recent exercise had been held on 

November 9, 1994, simulating a hazardous materials accident. 

Number of Passengers and Crew: Train No. 79 carried 162 passengers and 4 crewmembers, 

while train No. 12 carried 90 passengers, 3 crewmembers, and 24 deadheading employees. 

Passenger and Crew Injuries: On train No. 79, 1 passenger sustained minor injuries, while the 

other 161 passengers and 4 crewmembers were uninjured. On train No. 12, 2 deadheading 

employees sustained serious injuries; 2 crewmembers, 17 passengers, and 22 deadheading 

employees sustained minor injuries, while 1 crewmember and 73 passengers were uninjured. 

Cause of Death: Not applicable. 
142

Manifest Identified as Issue by NTSB: No. 

Other Issues Identified by NTSB: Amtrak management oversight of the inspection, 

maintenance, and repair of moveable bridge rail assemblies, and effectiveness of Amtrak’s 

emergency notification procedures 

Likely Impact of Having a Manifest: None. In accidents in which cars have remained upright 

and in which minimal structural damage to the cars and no passenger ejection has occurred, little 

danger exists to first responders in searching the cars for all passengers, and little likelihood 

exists that passengers would be missed in a search of the cars. In this case, the first responders 

would be reasonably sure that they had not missed any passengers in their search efforts; while 

an accurate manifest would be nice to have, it would not be essential to their efforts. 
143

Collision and Derailment of Maryland Rail Commuter MARC Train 286 and 

National Railroad Passenger Corporation Train 29 near Silver Spring, Maryland, 

February 16, 1996, NTSB Report Number RAR-97-02, adopted on 6/17/1997. 

Synopsis: On Friday, February 16, 1996, at 5:39 p.m., an eastbound Maryland Rail Commuter 

(MARC) train 286, operated by CSXT for the Maryland Mass Transit Administration (MTA) 

collided with the westbound Amtrak passenger train 29, Capitol Limited. The accident occurred 

during a blowing snowfall at a railroad location, referred to as Georgetown Junction, about 1 

mile west of Silver Spring, Maryland. Both trains were operating on the double main tracks 

owned and maintained by CSXT. 

The MARC train 286 was a push-pull commuter train consisting of a locomotive unit on the rear 

end, two passenger cars, and a passenger coach cab control car in the lead. The engineer was 

operating the train from the cab control car in the push mode at the time of the collision. The 

Amtrak train consisted of 2 locomotives and 15 cars. 

Amtrak train 29 had been routed onto track 2 from Union Station to Georgetown Junction to pass 

a stopped westbound CSXT freight train that occupied track 1 east of Georgetown Junction. The 

engineer of Amtrak train 29 stated he was beginning to negotiate the crossover from track 2 to 1 

at Georgetown Junction when the collision occurred. 

The left front quadrant of the MARC cab car (the leading passenger car) separated and was 

destroyed as a result of the collision. The fuel tank of the Amtrak lead locomotive ruptured on 

impact, and the diesel fuel ignited. Fire engulfed the rear superstructure of the locomotive. Fuel 

spilled onto the MARC cab car, ignited, and destroyed the car. 

On board the Amtrak train were 164 passengers, 13 OBS personnel, 4 operating crew, and 1 

mechanical rider. The engineer, assistant engineer, and conductor received minor-to-moderate 

injuries. 

The MARC train had 3 operating crewmembers and 20 passengers on board. Two crewmembers 

and 7 passengers died of smoke inhalation, and 1 crewmember and 1 passenger died as a result 

of impact injuries; 11 of the 12 survivors were injured. 

Type of Accident: Collision between on track equipment. 

Accident Result: MARC Train 286—The cars and locomotive of the train remained coupled 

and were situated approximately in a linear orientation, derailed but upright. Fuel spilled onto 

the MARC cab car, ignited, and destroyed the car. Because the running gear and batteries of the 

coaches were damaged in the derailment, the emergency lighting and public address system were 

inoperable. Amtrak Train 29—The locomotive units, the 1st, and 4th through 8th cars were all 

derailed (either one or both axles) but remained upright. The passenger-occupied 9th through 15th

cars remained on the track and were not damaged. All Amtrak cars in the consist remained 

upright and parallel to the track, except for the fifth and sixth cars. No damage was noted to 

passenger compartments. All emergency lighting had been illuminated immediately after the 
144

collision according to the conductor. The public address system remained operable after the 

collision and was used by the conductor for emergency broadcasts. 

Type of Train: MARC Train 286 was a commuter rail train, while Amtrak Train 29, the Capital 

Limited, was a reserved train. 

Type of Equipment: Amtrak Train 29 did have sleeper cars.

Time of day: 5:39 p.m.–darkness. 

Crew Training: CSXT personnel operating MARC passenger trains were not adequately 

trained to understand and, therefore, execute their responsibilities for passengers in emergencies. 

The NTSB report did not discuss Amtrak crew training. 

Crew Incapacitated: The 3 MARC crewmembers sustained fatal injuries. Two of the Amtrak 

operating crew sustained serious injures and 2 minor injuries, while one of the other crew 

sustained serious injures, 2 minor injuries, and 11 were uninjured.

Bystanders Involved: No. 

Timeliness of Emergency Response: The CSXT dispatcher was contacted about 5:41 p.m. by 

the traincrew of CSXT train K951, which was stopped on the adjacent track east of Georgetown 

Junction, that Amtrak train 29 had derailed while crossing over at Georgetown Junction. At 

approximately 5:41 p.m., the Montgomery County Fire and Rescue Services (MCFRS) 911 

dispatcher received approximately 12 telephone calls reporting the derailment and fire. At 5:44 

p.m., the dispatcher contacted the MCFRS to notify it of the accident and was informed that it 

was already aware of the derailment. About 5:46 p.m. (approximately 7 minutes after the 

accident) the first units arrived on scene. 

At 5:46 p.m., the first firefighter arriving on scene reported a fully engulfed passenger car, which 

he was unable to enter or open the doors. By 6:15 p.m., an emergency medical services 

command was established as well. 

The last victim was removed from the wreckage by 3:50 a.m. on February 17, and emergency 

operations were suspended. During the rescue operations, five on-scene triage sites were 

available for the injured victims, who were later transported to five area hospitals for treatment. 

Under Montgomery County Emergency Operations Center (EOC) direction, two nearby schools 

were used to provide victims with shelter, crisis counseling, and staging for transportation. 

County, emergency management, and volunteer agencies’ officials and members staffed the 

EOC. 

Training of Emergency Responders: Montgomery County simulated a Washington 

Metropolitan Area Transit Authority (WMATA) train derailment in Rockville in February 1995 

during which at least 24 people were transported to hospitals, and shelters were established with 

county agencies’ participation. In October 1995 another WMATA train derailment was 
145

simulated with casualties during a 30-inch snowfall. MCFRS had not participated in any disaster 

drills that involved MARC, Amtrak, or CSXT and in any disaster training or familiarization 

training with any freight or passenger railroad that provides service in Montgomery County. 

Number of Passengers and Crew: Three operating crewmembers and 20 passengers were on 

board the MARC train. The Amtrak train had 164 passengers, 13 OBS personnel, 4 operating 

crew, and 1 mechanical rider on board. 

Passenger and Crew Injuries: Three MARC crewmembers sustained fatal injuries, while 8 

passengers sustained fatal injuries, 3 serious injuries, 8 minor injuries, and 1 uninjured. Two of 

the Amtrak operating crew sustained serious injures and 2 minor injuries, 1 of the other crew 

sustained serious injures, 2 minor injuries, and 11 were uninjured, 8 passengers sustained minor 

injuries, and 156 were uninjured. 

Cause of Death: All fatalities were on MARC train 286. Two crewmembers and 7 passengers 

died of smoke inhalation, and 1 crewmember and 1 passenger died as a result of impact injuries. 

Manifest Identified as Issue by NTSB: No. 

Other Issues Identified by NTSB: Performance and responsibility of MARC crewmembers, 

Federal oversight of commuter rail operations, lack of positive train separation control systems, 

crashworthiness of locomotive fuel tanks, adequacy of passenger car safety standards, and 

emergency preparedness.

Likely Impact of Having a Manifest: None. Even though MCFRS personnel responded 

promptly to the emergency, they could do nothing to save any of the accident victims because 

passenger coach cab control car 7752 was already completely engulfed in flames when the first 

firefighter arrived on scene. 

The first firefighters to reach cab control car 7752 reported that the car was fully involved in fire 

and that they did not observe any survivors. They made several attempts to enter the cab control 

car. The fire was extinguished within 10 minutes, after which the firefighters were able to enter 

the car. They were later assisted by members of the Montgomery County Police Department in 

the recovery of 11 victims for coordinating the identification and notification process with the 

Maryland medical examiner. At 3:50 a.m. on Saturday, February 17, 1996, the last victim was 

recovered. 

The emergency egress of passengers was impeded because the passenger cars lacked readily 

accessible and identifiable quick-release mechanisms for the exterior doors, removable windows, 

kick panels in the side doors, and adequate emergency instruction signage. The exterior 

emergency door release handles for the MARC cars were either not in place or accessible to 

firefighters because no requirements for their maintenance or accessibility exist. 
146

The NTSB report notes: 

Amtrak reported to Safety Board investigators that about 6:15 p.m. one of its 

officers made four attempts within 10 minutes to provide the passenger list and 

other information to the MCFRS personnel at the command center in the adjacent 

parking lot. He was finally told that the information was not needed and he 

should wait. 
147

Amtrak Train 87 Derailment after Colliding with Intermodal Trailer from CSXT 

Train 176 Selma, North Carolina, May 16, 1994, NTSB Report Number RAR-95-

02, adopted on 3/21/1995. 

Synopsis: At 4:46 a.m. on Monday, May 16,1994, the southbound National Railroad Passenger 

Corporation (Amtrak) train 87, Silver Meteor, struck the intermodal trailer REAZ232980 on the 

northbound CSXT 176, on the CSXT Florence Division at Selma, North Carolina. Amtrak train 

87 consisted of a 2-unit locomotive and 18 cars (1 material handling car, 2 baggage cars, 10 

coach cars, 2 lounge cars, 1 buffet car, 1 sleeper car, and 1 dining car). CSXT 176, consisting of 

a 3-unit locomotive and 52 cars, was a trailer-on-flat-cat/container-on-flat-car train. 

After the collision, both Amtrak units and the next 17 cars derailed. (The second unit and all 

cars remained upright.) The lead unit broke free from the second unit, rolled over 270 degrees, 

and came to rest on the assistant engineer’s side. The locomotive fuel tank ruptured during the 

accident sequence, and fire ignited outside the cab compartment from the spilled diesel fuel. On 

Amtrak train 87, the assistant engineer was killed, the engineer sustained serious injuries, and 1 

OBS crewmember and 119 passengers received minor injuries. (The fire was outside the cab 

compartment of the unit and did not contribute to the assistant engineer’s death or the engineer’s 

injuries.) The operating crew on CSXT 176, the 3 other Amtrak operating crewmembers, 17 

other OBS crewmembers, and 296 passengers sustained no injuries. 

Type of Accident: Collision between on track equipment. 

Accident Result: Both locomotives and 17 of 18 cars derailed, the lead locomotive overturned, 

and all other derailed equipment remained upright. The lead locomotive’s fuel tank ruptured, 

and fire ignited outside the cab compartment. 

Type of Train: Train 87, the Silver Meteor, is a reserved train. 

Type of Equipment: Did have sleeper cars. 

Time of day: 4:36 a.m.–darkness. 

Crew Training: Not discussed in the NTSB report. 

Crew Incapacitated: The assistant engineer was killed, the engineer sustained serious injuries, 

and 1 OBS crewmember received minor injuries. 

Bystanders Involved: No. 
148

Timeliness of Emergency Response: After the collision, the conductor attempted to call the 

engineer, received no response, and then contacted the CSXT 176 crew using a handheld radio to 

summon help. At the same time, an assistant conductor exited the train and used a cellular 

telephone to contact emergency services. At 4:42 a.m. (6 minutes after the accident), the 

Johnston County Emergency Communications Center received a 911 call from an unidentified 

person reporting the train accident. The Johnston County dispatcher immediately notified fire, 

rescue, police, and emergency medical services units. The Smithfield Fire Department arrived 

on scene within 6 minutes of the 911 call and immediately commenced evacuating passengers 

from Amtrak train 87. A staging area was established at 4:55 a.m. in a parking lot adjacent to the 

accident site, and a command post was established at 5:00 a.m. An incident command system 

was implemented to coordinate all fire and rescue activities at the accident site, and the chief of 

the Smithfield Fire Department assumed the duties of incident commander. At that time, the 

Johnston County disaster plan was put into effect. The CSXT dispatcher in Jacksonville, 

Florida, had been notified by the CSXT 176 crew and then contacted the Johnston County 

authorities about the accident at 4:46 and 4:47 a.m., respectively. 

In several passenger cars, the emergency windows, the fire extinguishers, and the first aid kits 

had been removed. No intrusions occurred in the passenger cars. The fixed emergency lighting 

systems were not operating inside several passenger cars. Batteries and the wiring connecting 

the batteries to the lights were damaged as a result of the derailment. Three of the injured 

passengers, interviewed after the accident, reported difficulty exiting the passenger cars because 

they could not see the emergency exit windows in the darkness. When they were finally able to 

escape through the doors leading outside, they said that they were not sure how far they were 

above a surface, which may not have been solid ground, because they could not see below the 

steps of the car. 

The transport of injured passengers and Amtrak crewmembers to the two hospitals was executed 

expeditiously. The hospitals were notified immediately after the accident and instituted their 

disaster plans for receiving heavy casualties. 

Training of Emergency Responders: The Johnston County Office of Emergency Management 

conducted a disaster preparedness exercise in January1994, which simulated the evacuation of 

residents during a woodlands fire that spread into an urban area. 

Amtrak provided training to Johnston County fire and rescue agencies in January 1995 (after the 

accident). The 3-hour training session included familiarization with Amtrak equipment, location 

of emergency gear, avoidance of high voltage electrical equipment after an accident, and 

evacuation of passengers from Amtrak trains. 

Number of Passengers and Crew: 415 passengers, 5 operating crewmembers, and 18 OBS 

crewmembers. 

Passenger and Crew Injuries: On Amtrak train 87, the assistant engineer was killed, the 

engineer sustained serious injuries, and 1 OBS crewmember and 119 passengers received minor 
149

injuries. The operating crew on CSXT 176, the 3 other Amtrak operating crewmembers, 17 

other OBS crewmembers, and 296 passengers sustained no injuries. 

Cause of Death: Not applicable. 

Manifest Identified as Issue by NTSB: No. 

Other Issues Identified by NTSB: The loading, securement, and inspection of intermodal 

trailers onto railroad flatcars, locomotive operating compartment crashworthiness, locomotive 

fuel tank crashworthiness, and failure of the emergency lighting system. 

Likely Impact of Having a Manifest: None. In accidents in which cars have remained upright 

and in which minimal structural damage to the cars and no passenger ejection has occurred, little 

danger exists to first responders in searching the cars for all passengers, and little likelihood 

exists that passengers would be missed in a search of the cars. In this case, the first responders 

would be reasonably sure that they had not missed any passengers in their search efforts; while 

an accurate manifest would be nice to have, it would not be essential to their efforts. 
150

Derailment of Amtrak Train 49 on Conrail Trackage near Batavia, New York, on 

August 3, 1994, NTSB Report Number RAR-96-02, adopted on 7/11/1996. 

Synopsis: Train 49, the Lake Shore Limited, was a regularly scheduled westbound train that 

traveled from New York, New York, to Chicago, Illinois. The train consisted of 2 locomotive 

units, 2 MHCs, 1 baggage car, 12 passenger cars (3 sleepers), and 1 baggage/dormitory car. 

At approximately 3:42 a.m., it reached the point where the initial derailment occurred. The train 

continued west and passed the head end of a Conrail freight train. The freight train on the 

adjacent track was also moving west. According to the Conrail train engineer and conductor, 

sparks and gravel were coming from the underside of either the second or third car behind the 

locomotive units of train 49. The crew of the freight train attempted to alert the crew of train 49 

by radio. 

No response was received from the initial attempt. Train 49 responded to the second attempt, but 

the general derailment occurred almost simultaneously. At the time, train 49 had a clear 

(proceed) signal indication and was traveling, according to the event recorder, about 79 mph. 

The event recorder data strip also indicated that the emergency brakes were initiated by a train 

line separation after the general derailment had occurred. Fourteen cars of the 18-car consist had 

derailed. A signal bridge was struck in the derailment, and the bridge fell onto two of the cars. 

Type of Accident: Derailment. 

Accident Result: The locomotives and four cars did not derail, five derailed cars remained 

upright within the track structure, three cars remained upright but were tilted, and five cars were 

overturned. 

Type of Train: Train 49, the Lake Shore Limited, is a reserved train. 

Type of Equipment: Did have sleeper cars.

Time of day: 3:44 a.m.–darkness.

Crew Training: Not discussed in the NTSB report. 

Crew Incapacitated: Three operating crewmembers and seven service crewmembers sustained 

minor injuries. 

Bystanders Involved: No. 
151

Timeliness of Emergency Response: The general derailment occurred near a Conrail police 

unit that was doing a routine check of Conrail construction equipment. The Conrail police 

officer notified the Conrail dispatcher, who advised the Genesee County Emergency 

Communication Center (GCECC) of the derailment at 3:46 a.m. The GCECC dispatcher 

immediately sent a sheriff’s deputy to the accident scene and at 3:55 a.m. informed the Batavia 

town and city fire departments, as well as at least 11 other emergency services. 

The fire chief arrived at the accident scene within 15 minutes of the accident, assumed 

command, and requested additional ambulances and helicopters. The New York State (NYS) 

police were notified at 4:03 a.m. and responded. GCECC arrived on scene at 4:08 a.m. and 

called for every available ambulance, rescue unit, and extrication tool. Staging areas for 

ambulances, helicopters, and fire and rescue equipment were established at a nearby plant and on 

the south side of the tracks, respectively. 

An emergency shelter was established at 5 a.m. in the town of Batavia fire hall. The NYS police, 

who were in charge of transporting the train passengers by bus, listed the names of the injured 

passengers before taking them to the emergency shelter, where their need for hospitalization was 

evaluated. During this evaluation, several more passengers asked to be taken to hospitals. 

Seriously injured passengers had been removed from the accident scene by 5 a.m., and the last 

passenger left the scene at 6:15 a.m. 

Some passengers reported that they had no difficulty in evacuating the cars; others, however, 

said that the evacuation was difficult. Several passengers in the cars that had turned on their 

sides stated that they had trouble reaching the exposed side windows. Other passengers said that 

they could not open the heavy car-end doors. Darkness, the steep embankment, and the awkward 

position of the cars were other reasons attributed to a difficult evacuation. 

Training of Emergency Responders: The last disaster drill, according to GCEMC, had been in 

September 1993 and simulated a hazardous material spill accident in which five fatalities and 

two injuries occurred at a rest stop on an interstate highway. 

In October 1994 (after the accident) at the NYS Fire Academy, Amtrak presented to emergency 

response agencies its 3-hour training course, which includes how emergency responders should 

interact with Amtrak crewmembers, what emergency responders should know about Amtrak 

equipment, and how to evacuate Amtrak trains. Genesee County emergency response agencies 

participated in this training. In April and May 1995, Amtrak provided passenger cars for use in 

disaster drills in five communities near the site of the Batavia derailment. 

Number of Passengers and Crew: 320 passengers, 5 operating crewmembers, and 14 OBS 

crewmembers. 

Passenger and Crew Injuries: 25 passengers sustained serious injuries, 3 operating 

crewmembers, 7 service crewmembers, and 83 passengers sustained minor injuries, while 2 

operating crewmembers, 7 service crewmembers, and 212 passengers were uninjured. 
152

Cause of Death: Not applicable. 

Manifest Identified as Issue by NTSB: No. 

Other Issues Identified by NTSB: Lack of guidelines related to flattened rail head conditions 

and integrity of passenger car seats. 

Likely Impact of Having a Manifest: None. In accidents in which cars have overturned and 

suffered structural damage a possibility exists for passenger ejection and/or entrapment. In this 

case, passenger ejection/entrapment was not an issue. The potential safety benefits of having an 

accurate manifest in terms of improving passenger survivability are minimized by the fact that 

counting evacuated passengers takes hours. 
153

Collision of Amtrak Train No. 88 with Rountree Transport and Rigging, Inc., 

Vehicle on CSXT, Railroad near Intercession City, Florida, November 30, 1993, 

NTSB Report Number HAR-95-01, adopted on 5/16/1995. 

Synopsis: On November 30, 1993, a 184-foot long vehicle consisting of a truck-tractor and 

modular transporter was en route to deliver an 82-ton turbine to a Kissimmee Utility Authority 

(KUA) electricity generating plant under construction near Intercession City, Florida. The 

private access road to the plant facility crosses over a single railroad track owned by CSXT. 

Because of the configuration of the truck and the profile of the roadway, the cargo deck of the 

transporter began to bottom out on the roadway surface as the vehicle moved across the tracks 

and began down the descending grade. At approximately 12:40 p.m., after the truck’s crew had 

finished raising the cargo deck and were preparing to move the vehicle, the lights and bells at the 

grade crossing activated. The crossing gates descended, striking the turbine. Seconds later, 

National Railroad Passenger Corporation (Amtrak) train No. 88, the Silver Meteor, carrying 89 

passengers, struck the side of the cargo deck and the turbine. The locomotive and the first four 

cars of the eight-car consist derailed, carrying the turbine and parts of the vehicle with them. 

No deaths resulted from this accident. Responders evacuated 59 people to 5 local hospitals, 

where 15 were admitted for further treatment. Six people sustained serious injuries, and 53 

suffered minor injuries, mostly abrasions, lacerations, and contusions. 

Type of Accident: Highway-rail collision/impact. 

Accident Result: The locomotive and the first four cars of the eight-car consist derailed. The 

derailed cars were tilted but did not overturn. 

Type of Train: The Silver Meteor is a reserved train. 

Type of Equipment: Did have sleeper cars. 

Time of day: 12:40 p.m.–daylight. 

Crew Training: Amtrak personnel records indicate that OBS crewmembers had received 

training in emergency evacuation procedures. Two employees took the training in August 1993, 

one in January 1985, and one in May 1987. The personnel file for the fifth employee did not 

indicate a training date. 

Crew Incapacitated: Two of the train crew sustained serious injuries, three of the train crew 

sustained minor injuries, while five of the train crew were uninjured. 

Bystanders Involved: No. 

Timeliness of Emergency Response: At 12:45 p.m., a resident called the Osceola County 

Communications Center and reported a “train derailment at 6030 Old Tampa Highway.” Eight 

rescue and fire units initially responded. The Osceola battalion fire chief assumed responsibility 
154

as incident commander and established a command post and triage area near Old Tampa 

Highway when he arrived on scene within 12 minutes of the collision. He radioed area hospitals 

to activate their disaster plans and requested medical evacuation (Medivac) helicopters. He 

directed responders to begin efforts to extricate the crewmembers trapped in the locomotive and 

to conduct a sweep of each railroad car to identify, classify, and tag patients. No fire resulted 

from the accident. 

Responders evacuated all passengers from the train within an hour of the accident. Osceola Fire 

Rescue personnel had to remove the roof hatch of the overturned locomotive to extricate the 

trapped engineer and assistant engineer. Within 2 1⁄2 hours of the accident, response personnel 

had transported 59 injured to area hospitals, where 15 were admitted for further treatment. Most 

of the injured were transported by ambulance or bus to area hospitals, where they were treated 

for minor abrasions, lacerations, and contusions. Two air ambulance helicopters evacuated five 

of the six seriously injured. 

Passengers were able to use the exits from most coaches. However, after the train came to rest, 

several coaches were tilted, which precluded using the step devices that OBS personnel usually 

place on station platforms to facilitate exit from the train. Responders stacked railroad ties at 

some coaches to form steps at the exits. Other coaches were so tilted that emergency response 

personnel had to lower several passengers from the windows. 

Training of Emergency Responders: Not discussed in the NTSB report. 

Number of Passengers and Crew: 89 passengers and 10 crewmembers. 

Passenger and Crew Injuries: Two of the train crew and 3 passengers sustained serious 

injuries, 3 of the train crew and 50 passengers sustained minor injuries, while 5 of the train crew 

and 36 passengers were uninjured. 

Cause of Death: Not applicable. 

Manifest Identified as Issue by NTSB: No. 

Other Issues Identified by NTSB: Coordination of oversize vehicle moves, and pipeline 

hazard identification, notification, and avoidance. 

Likely Impact of Having a Manifest: None. In accidents in which cars have remained upright 

and in which minimal structural damage to the cars and no passenger ejection has occurred, little 

danger exists to first responders in searching the cars for all passengers, and little likelihood 

exists that passengers would be missed in a search of the cars. In this case, the first responders 

would be reasonably sure that they had not missed any passengers in their search efforts; while 

an accurate manifest would be nice to have, it would not be essential to their efforts. 
155

Derailment of Amtrak Train No. 2 on the CSXT Big Bayou Canot Bridge Near 

Mobile, Alabama, September 22, 1993, NTSB Report Number RAR-94-01, 

adopted on 9/19/1994. 

Synopsis: On September 22, 1993, at approximately 2:45 a.m., barges that were being pushed 

by the towboat MAUVILLA in dense fog struck and displaced the Big Bayou Canot railroad 

bridge near Mobile, Alabama. At approximately 2:53 a.m., Amtrak train No. 2, the Sunset 

Limited, with 220 persons on board, struck the displaced bridge and derailed. The three 

locomotive units, the baggage and dormitory cars, and two of the six passenger cars fell into the 

water. The fuel tanks on the locomotive units ruptured, and the locomotive units and the 

baggage and dormitory cars caught fire. Forty-two passengers and 5 crewmembers were killed; 

103 passengers were injured.

 

Type of Accident: Derailment. 

Accident Result: The three locomotive units came to rest on the east side of the bayou. Part of 

the lead unit was buried in about 46 feet of mud, and the part protruding above the embankment 

burned. The second unit also burned. The baggage car and dorm-coach, also on the east side of 

the bayou, were gutted by fire. About half of the first coach, which rested against the bridge 

after the accident was submerged, and the second coach was almost totally submerged. The last 

four cars, a coach, lounge, diner, and sleeper, remained on the bridge. All passenger cars were 

double-decker cars. 

Type of Train: Train 2, the Sunset Limited, is a reserved train. 

Type of Equipment: Did have sleeper cars. 

Time of day: 2:53 a.m.–darkness. 

Crew Training: Unknown. 

Crew Incapacitated: Of the operating crew, three sustained fatal injuries, two minor injuries, 

and one was uninjured, while two of the OBS crew sustained fatal injuries, six minor injuries, 

and four were uninjured.

Bystanders Involved: Yes. At approximately 3:19 a.m. (26 minutes after the accident), the 

captain of the MAUVILLA called and advised the Coast Guard that he had his barges under 

control. He further stated that he would try to render assistance to survivors. The 

MAUVILLA’s deckhands launched the towboat’s skiff, which was near the wreckage on the east 

side of the river, and one deckhand rowed to people in the water and pulled them aboard. He 

returned several times to pick up additional survivors. 

At approximately 3:59 a.m. (over 1 hour after the accident), the towboat SCOTT PRIDE, 

approached the accident site. The crew of the SCOTT PRIDE pulled 20 people out of the water. 

The crew of the MAVILLA rescued 17 people from the water. 
156

Timeliness of Emergency Response: At approximately 2:56 a.m., train No. 2’s assistant 

conductor made a “Mayday, Mayday” transmission over the railroad-designated radio that was 

heard by CSXT train 579, whose crew repeated it to the yardmaster at the Sibert Yard, Mobile. 

Also at about 2:56 a.m., the assistant terminal trainmaster at Sibert Yard heard train No. 2 

transmitting Mayday over the radio. The yardmaster at Sibert Yard notified the train dispatcher 

in Jacksonville, Florida, at 2:57 a.m. and the Mobile Police Department’s 911 operator about 3 

a.m. that Train 2 had derailed. The telephone number for the Coast Guard in the Mobile 

telephone directory was incorrect, and both the yardmaster and the CSXT representative in 

Mobile did not succeed in their first attempts to contact the Coast Guard. 

The bridge tender at the Mobile River Bridge and the train engineer of Train 579 also radioed the 

train dispatcher in Jacksonville at approximately 2:56 a.m. that train No. 2 was transmitting a 

Mayday call. Immediately thereafter, the train dispatcher tried to contact train No. 2 but was 

unsuccessful. Train 579’s engineer advised the dispatcher that train No. 2 had derailed at the 

Mobile River Bridge, which is where the assistant conductor said he thought the train was when 

he made his Mayday call, and was on fire. The Mobile River Bridge is about 3.2 miles north of 

the actual accident site. 

Between 3:02 and 3:05 a.m., the Mobile Police Department’s 911 operator contacted the Mobile 

Fire Department and the Coast Guard. Police, fire, and Coast Guard personnel began notifying 

other emergency responders; more than 60 local departments eventually responded. Train No. 

2’s OBS supervisor, using a cellular telephone, called the Mobile 911 operator about 3:05 a.m. 

and provided additional information about the accident location and what was taking place at the 

site. The OBS supervisor, however, did not know the exact location of the derailment. For 

about 18 minutes—from 3:02 to 3:20 a.m.—confusion ensued as the Mobile, Saraland, and 

Chickasaw 911 operators tried to locate the accident site. Exactly where train No. 2 had derailed 

was unclear, and no roads lead into the area, which is heavily wooded swampland. Before they 

knew they would have to respond by water or rail, the emergency responders searched by land 

for the accident site. 

The Mobile fireboat RAMONA DOYLE arrived about 4 a.m. (over 1 hour after the accident) 

and, after determining that no other people remained in the water, started fighting the fire. 

At approximately 4:25 a.m., the Coast Guard’s rigid-hull inflatable boat arrived and started 

assisting passengers. Coast Guard helicopters arrived on scene about 5:20 a.m. and started 

assisting passengers. The MAUVILLA transported the survivors it had rescued to a triage area 

at the Scott Paper Company pier in Chickasaw. Coast Guard, local emergency medical services 

personnel, and other towboats that responded to the distress call also took survivors to the two 

triage sites established at the Scott Paper Company in Chickasaw. The last survivors were 

treated and transported to local hospitals or hotels by 8:30 a.m. 

Training of Emergency Responders: Although the Mobile County Emergency Management 

Agency (MCEMA) held drills to simulate transportation accidents before this accident, those 

drills did not include simulations of an accident involving railroad operations. Amtrak 

representatives had to show divers searching the submerged cars the layout of cars that remained 

on the bridge because the divers were not familiar with the train equipment. Since the accident, 
157

floor plans and videotape describing Amtrak’s emergency procedures have been provided to the 

Mobile Fire Department. 

Number of Passengers and Crew: The ticket count on the day after the accident indicated that 

189 passengers and 18 employees (6 operating and 12 OBS) were on board the Sunset Limited. 

Rescuers recovered 3 unticketed infants, bringing the passenger and crew count to 210. An 

Amtrak representative later told NTSB investigators that, after the accident, 10 additional people 

reported that they had been passengers on the train. Because passengers board and exit at 

various stops and because some passengers purchase tickets on board instead of making 

reservations, Amtrak could not determine whether these 10 people were on train No. 2 during the 

derailment. Nonetheless, they have been included in the passenger and crew count, bringing the 

total to 220. 

Passenger and Crew Injuries: Of the operating crew, 3 sustained fatal injuries, 2 minor 

injuries, and 1 was uninjured, while 2 of the OBS crew sustained fatal injuries, 6 minor injuries, 

and 4 were uninjured. Of the passengers, 42 sustained fatal injuries, 4 serious injuries, 99 minor 

injuries, and 57 were uninjured. 

Cause of Death: Autopsy reports show that 42 passengers died from asphyxia due to drowning. 

Three locomotive engineers died as a result of asphyxia and blunt force trauma while inside the 

lead locomotive unit cab that became filled with mud. Two OBS crewmembers in a section of 

the dorm-coach that sustained major structural damage died as a result of smoke inhalation. 

Manifest Identified as Issue by NTSB: Yes. 

Other Issues Identified by NTSB: Towboat operator training and evaluation, bridge risk 

assessment, bridge identification, portable emergency lighting, procedures for apprising 

passengers of safety features, train recorder crashworthiness, inadequate emergency response 

training related to passenger train accidents 

Likely Impact of Having a Manifest: None. The first emergency responders did not arrive 

until 1 hour after the accident. The 42 passengers who drowned died within minutes of the cars 

entering the water. Fellow passengers, the surviving train crew, and the crew of the towboat that 

had struck the bridge and another towboat that was in the vicinity rescued passengers. 

During rescue activities on the day of the accident, an Amtrak representative provided the 

incident commander with a partial passenger and crew list and told him that about 200 people 

were on board. A list compiled later the next day showed 207 people. The delay in providing 

the exact count caused problems because the incident commander had to assign personnel to 

spend a day counting tickets to help develop a passenger list. In addition, emergency responders 

did not know when to discontinue operations because the count changed frequently. The railroad 

was not aware that three infants were on board because they were not ticketed. 

Since most OBS crewmembers were asleep in the dorm-coach and since the train attendants were 

in the cars on the bridge, passengers in the submerged cars had to make decisions on their own 

and evacuate without assistance. 
158

According to passengers in the totally submerged car (coach 34068), the lower level and front 

section of the car filled with water in seconds, limiting the time passengers in those sections had 

to evacuate. The center and rear sections on the upper level remained out of the water for about 

10 minutes, and passengers evacuated through the open rear door and window exits on the upper 

level. 

The assistant conductor told passengers atop the coach that was partially submerged and sinking 

(coach 34083) to swim to the east bank toward the rear of the train. Passengers inside this coach 

stated that the lower level and rear of the car filled with water in seconds, limiting the evacuation 

time for passengers in those sections. Bridge timbers held the upper level and front of the car out 

of the water; passengers in those sections evacuated through the window exits on the upper level 

in about 30 minutes. 

The OBS supervisor and three OBS crewmembers (the other eight OBS crewmembers were in 

the dorm-coach, which was burning on the east side of the bayou) began evacuating the cars that 

remained on the bridge. They evacuated them to the tracks at the rear of the train. 

The assistant conductor set up a relay system in the water with passengers who could swim. The 

assistant conductor instructed passengers participating in the relay to space themselves “about 20 

yards apart” and to “swim out and meet these elderly people [who were evacuating from 

submerged cars] and swim them to the next guy and so forth, on up to the bank.” The relay 

passed people from the middle of the waterway to the west bank of the bayou. 

Six OBS crewmembers evacuated from the dorm-coach, which was on fire. They entered the 

water, were rescued by the crew of the towboat MAUVILLA, and then helped passengers out of 

the water. 

When the towboats and traincrew had rescued most of the people from the water, the conductor 

and assistant conductor began taking a head count of the passengers and passed out blankets and 

pillows. The OBS supervisor distributed cushions, and the assistant conductor informed the 

passengers that a train would take them back to Mobile. 

After emergency responders arrived at the accident site, they began rescue operations, recovery 

of bodies, triage, and firefighting activities. The Coast Guard on-scene commander provided 

assistance and resources, including planes, helicopters, boats, and manpower, throughout the 

emergency. The MAUVILLA’s crew, SCOTT PRIDE personnel, train crewmembers, and 

volunteers were all instrumental in rescuing people from the water and evacuating passengers 

from the train immediately following the accident. 
159

Appendix E. Emergency Preparedness Guidelines for Passenger Trains 

CFR Part 239–Passenger Train Emergency Preparedness–became effective May 4, 1998. These 

regulations attempt to address many of the issues raised in various NTSB reports. 

CFR Part 239 prescribes minimum standards for the preparation, adoption, and implementation 

of emergency preparedness plans by railroads operating passenger trains. FRA must approve 

plans. 

Plans shall include the following elements: 

(1) Communication 

(2) Employee training and qualification 

(3) Joint operations 

(4) Special circumstances 

(5) Liaison with emergency responders 

(6) Onboard emergency equipment 

(7) Passenger safety information 

CFR Part 239 indicates that Amtrak is required to conduct a full-scale emergency simulation 

during each calendar year. Further, Amtrak is required to conduct a debriefing and critique 

session within 60 days of the emergency simulation or an actual passenger train emergency 

situation.3

 Amtrak is required to maintain records of these debriefings for 2 calendar years and 

make them available to FRA for inspection and copying. 

CFR Part 239 seems to be loosely based on a 1993 Volpe study for FRA, Recommended 

Emergency Preparedness Guidelines for Passenger Trains.4

 Relevant highlights from that report 

are provided below. 

“An understanding of the types of emergencies, which could occur, and their related hazards is 

necessary for effective emergency preparedness planning and specific protocol and procedure 

development. Typical emergency scenarios include illness or injury, stalled train, sudden stop of 

train, suicide/other collision with a person, collision/derailment, fire, collision/derailment and 

 

3

 Emergency or emergency situation means an unexpected event related to the operation of passenger train service 

involving a significant threat to the safety or health of one or more persons requiring immediate action, including: 

(1) A derailment 

(2) A fatality at a grade crossing 

(3) A passenger or employee fatality, or serious illness or injury to one or more passengers or 

crewmembers requiring admission to a hospital 

(4) An evacuation of a passenger train 

(5) A security situation (e.g., a bomb threat) 

4

 Markos, Stephanie H., Emergency Preparedness Guidelines for Passenger Trains ,Report No. DOT/FRA/ORD93/24, prepared for Federal Railroad Administration, Office of Research and Development, John A. Volpe National 

Transportation Systems Center, Cambridge, December 1993. 
160

fire, collision/derailment with water immersion, severe weather conditions/natural disasters, and 

security situations (e.g., bombings, bomb threats, hijackings, civil disorders, and acts of 

terrorism). It is quite possible that an emergency could involve a combination of these 

scenarios.” (p. 2-2) 

“Many serious injuries and damage to train equipment may occur as a result of a train derailment 

and/or collision. Persons may be injured from impact forces or being trapped by mangled or 

twisted car body or interior components. The priority for the train crew, if a derailment/collision 

occurs which does not involve fire or other immediate danger, is to notify the Train 

Dispatcher/Control Center personnel who will inform the appropriate emergency response 

organization(s). Stabilization of train equipment to reduce hazards may be necessary. Removing 

electrical power from downed or damaged power lines and the third rail must be arranged. If a 

person suffers a life threatening injury, first aid from the train crew or fellow passengers may 

help. Rapid evacuation is generally secondary to immediate treatment by emergency response 

organization personnel, unless staying on the train is itself life-threatening. Once injured 

passengers are medically stabilized, they will be removed and transported to a medical facility.” 

(p. 2-8) 

“The occurrence of a train or facility fire/smoke situation is a potentially life-threatening event 

which may require rapid evacuation of all individuals from the affected cars or area to avoid 

casualties resulting from burns, or toxic gas inhalation. Fire often causes panic and confusion; 

smoke may decrease visibility, making it difficult for passengers, train crew, and other passenger 

train system operating organization and emergency response personnel to find emergency exits 

(and access points).” (p. 2-9) 

“A train derailment/collision that involves fire or smoke is one of the most serious emergency 

scenarios, which could occur. Spilled or leaking fuel can ignite. The hazards of the fire/smoke 

scenario are aggravated by the possibility that the train crew and many passengers may sustain 

injury during a collision or derailment and may require immediate medical treatment. This 

combination of events makes it more difficult than for either condition separately, yet evacuation 

is even more imperative. Immediate evacuation of injured passengers takes precedence over 

medical treatment.” (p. 2-9) 

“A derailment/collision that results in passenger cars and/or motive power units being immersed 

in water is another situation in which evacuation is critical. Passengers and crew may drown, 

whether injured or not in the initial accident, unless other crew or passengers aid them until 

emergency response personnel arrive. Fire caused by ignited fuel oil, which has spread onto the 

water surface, is an added hazard. As in the previous scenario, immediate evacuation of injured 

persons takes precedence over treatment.” (p. 2-10) 

“However, train location, the time of day, day of week, season of the year, and weather could 

affect the ability of the appropriate emergency response organization to take action or gain 

access to the site of the emergency. Personnel may also be unavailable or may be unable to 

respond immediately because they do not possess sufficient information or must perform other 

duties (e.g., all personnel could be responding to another emergency).” (p. 2-19) 
161

“Due to the magnitude of the emergency or its isolated location, it may be difficult to notify the 

Train Dispatcher/Control Center. Moreover, due to the lack of (or delay in) emergency response 

organization notification or due to the location of the emergency, emergency response 

organization personnel may not immediately reach the emergency site. The train crew should 

assess the situation and, if uninjured, provide the necessary initial response until emergency 

personnel arrive, particularly if a life-threatening situation makes it necessary to evacuate 

passengers. This response should include making PA announcements by one of the train crew or 

onboard service employees, under the direction of the conductor, to keep passengers informed 

and provide directions. All individuals traveling on board the passenger train should be 

accounted for (particularly car compartments) so as to expedite evacuation, if necessary, and to 

avoid needless efforts to search for “missing” persons.” (p. 3-12) 

“When arriving at the emergency scene, emergency response personnel must assess the situation 

and determine what actions to take. Due to their knowledge and experience with train 

operations, the train crew and onboard service employees can provide valuable information and 

assistance to the “incident” officer-in-charge during an emergency. The train crew (and if 

necessary, onboard service employees) should convey the exact number and location of 

passengers on board the train to the incident officer-in-charge. (In case of reserved intercity 

trains, this information may be available from another “division” of the passenger train system 

operating organization.) This information will assist response personnel in deciding whether 

evacuation is necessary and what type and level of additional resources are required. 

Once the incident officer-in-charge has completed the assessment and has requested the 

necessary further assistance, that person should appoint certain individuals to control hazards, 

other individuals to maintain support operations, and others to locate victims. As mentioned 

previously, all individuals should be accounted for (particularly in sleeping car compartments) in 

order to expedite evacuation and to avoid efforts to search for “missing” persons. Some 

passengers may have already been removed from the train and/or right-of-way/wayside facility 

by passersby or may have wandered from the scene.” (p. 3-13) 

“Once emergency response personnel gain access to the inside of the passenger car, or motive 

power unit, and if necessary, begin to treat persons to stabilize their conditions, they must decide 

how best to prepare individuals who are trapped for removal and transfer from the train or other 

location. In some cases, extrication may have to be concurrent with medical treatment to 

minimize danger to both victims and emergency response personnel from spilled fuel or other 

hazards. The decision to extricate injured persons should only be made jointly by the EMS 

technician or otherwise qualified emergency response individual already inside the train (or at 

other location) and the emergency response organization officer-in-charge. 

If no emergency response personnel are on the scene during a life-threatening situation, if their 

arrival time is unknown or delayed and if the train is located in an isolated area, it may be 

necessary for the train crew, onboard service employees, or other passenger train operating 

system operator personnel, or “Good Samaritans” to take some type of extrication and removal 

action to avert major injuries to or death of individuals who are trapped.” (p. 3-19) 
162

“If passengers are on a disabled train but are not injured or face no imminent danger, they could 

safely await the arrival of trained personnel with appropriate evacuation equipment. However, in 

a serious emergency involving smoke or fire, passengers may have to evacuate the train before 

emergency response personnel arrive. Thus, passenger train system operators should take steps 

to increase passenger awareness about the train system and basic evacuation procedures and 

equipment. Since passengers could inadvertently jeopardize their safety, it is appropriate for 

them to take the initiative only if the train crew or onboard service employees are incapacitated.” 

(p. 4-25) 
163

Appendix F. Amtrak Injury/Fatality Accidents by Type of Service 

Table 13. Amtrak Accidents Resulting in Passenger Injury/Fatality 

Sleeper Trains

Year Month Day Event Train Name Location St

Passengers 

Killed 

Pa

I

1993 February 23 Derailment City of New Orleans Memphis TN 0 1993 March 17 Highway-rail collision/impact Silver Meteor/Palm/Star Fort Lauderdale FL 0 1993 May 21 Derailment Silver Meteor Miami FL 0 1993 August 3 Highway-rail collision/impact Southwest Chief Lamar CO 0 1993 September 22 Derailment Sunset Limited Akka AL 42 1993 November 30 Highway-rail collision/impact Silver Meteor Russell FL 0 1993 December 21 Highway-rail collision/impact Three Rivers Hammond IN 0 1994 March 3 Highway-rail collision/impact California Zephyr Platteville CO 0 1994 May 16 Collision-between on track equipment Silver Meteor Selma NC 0 1994 August 3 Derailment Lake Shore Limited Batavia NY 0 1995 May 2 Highway-rail collision/impact Silver Star Fairfax SC 0 1995 October 9 Derailment Sunset Limited Gillespie AZ 0 1996 March 5 Highway-rail collision/impact Southwest Chief Albuquerque NM 0 1996 March 24 Collision with obstacle on track Empire Builder Spokane WA 0 1997 January 18 Highway-rail collision/impact Crescent Rapidan VA 0 1997 February 5 Highway-rail collision/impact Silver Meteor Jacksonville FL 0 1997 February 13 Highway-rail collision/impact Crescent Leeds AL 0 1997 July 8 Derailment Silver Palm/Star Alexandria VA 0 1997 August 9 Derailment Southwest Chief Kingman AZ 1 1997 September 29 Highway-rail collision/impact Silver Star Raleigh NC 0 1997 October 9 Highway-rail collision/impact Silver Star Savannah GA 0 1997 October 31 Derailment Empire Builder Chicago IL 0 1997 December 30 Highway-rail collision/impact Coast Starlight Morgan Hill CA 0 
164

Table 13. Amtrak Accidents Resulting in Passenger Injury/Fatality 

Sleeper Trains (continued)

Year Month Day Event Train Name Location St

Passengers 

Killed 

Pa

I

1998 March 10 Highway-rail collision/impact Silver Star Winter Haven FL 0 1998 April 13 Derailment Three Rivers Baden PA 0 1998 April 21 Highway-rail collision/impact Coast Starlight King City CA 0 1998 May 28 Highway-rail collision/impact California Zephyr Yuma CO 0 1998 August 4 Highway-rail collision/impact Crescent Tyler MS 0 1998 July 11 Highway-rail collision/impact Coast Starlight Moorpark CA 0 1998 December 20 Derailment Texas Eagle Arlington TX 0 1999 March 15 Highway-rail collision/impact City of New Orleans Bourbannais IL 11 1999 July 8 Highway-rail collision/impact Sunset Limited Eagle Lake TX 0 1999 September 20 Collision-between on track equipment Capitol Limited Cumberland MD 0 1999 October 22 Derailment Sunset Limited Palm Springs CA 0 1999 November 4 Highway-rail collision/impact Coast Starlight Salinas CA 0 1999 December 10 Highway-rail collision/impact Crescent Russell MS 0 2000 January 6 Derailment Empire Builder Essex MT 0 2000 January 29 Derailment Capitol Limited Stewarton PA 0 2000 March 15 Derailment Southwest Chief Carbondale KS 0 2000 April 29 Highway-rail collision/impact Coast Starlight Castroville CA 0 2000 May 19 Highway-rail collision/impact Palmetto Fort Lauderdale FL 0 2000 August 21 Derailment Silver Meteor Lake City SC 0 2001 February 4 Highway-rail collision/impact Southwest Chief Macksville KS 0 2001 February 15 Highway-rail collision/impact Three Rivers Gary IN 0 2001 March 17 Derailment California Zephyr Nodaway IA 1 2001 July 15 Highway-rail collision/impact Coast Starlight Newark CA 0 2001 July 29 Derailment Texas Eagle Annapolis MO 0 2001 September 11 Collision-between on track equipment Texas Eagle Hallsville TX 0 2001 September 13 Collision-between on track equipment California Zephyr Wendover UT 0 
165

Table 13. Amtrak Accidents Resulting in Passenger Injury/Fatality 

Sleeper Trains (continued)

Year Month Day Event Train Name Location St

Passengers 

Killed 

Pa

I

2002 February 17 Struck against object Southwest Chief Raton NM 0 2002 March 19 Highway-rail collision/impact Crescent Birmingham AL 0 2002 April 18 Derailment Auto Train Crescent City FL 4 2002 May 14 Highway-rail collision/impact Silver Meteor Ridgeland SC 0 2002 June 17 Collision-between on track equipment Palmetto Baltimore MD 0 2002 July 29 Derailment Capitol Limited Kensington MD 0 2002 July 29 Highway-rail collision/impact Coast Starlight Castroville CA 0 2002 July 30 Highway-rail collision/impact Silver Star Haines City FL 0 2002 August 21 Derailment Coast Starlight Hayward CA 0 2002 October 10 Derailment Empire Builder Chicago IL 0 2003 April 23 Collision-between on track equipment Coast Starlight Castella CA 0 2003 May 6 Highway-rail collision/impact Silver Star McIntosh GA 0 2003 August 28 Highway-rail collision/impact Crescent Bristow VA 0 2003 November 26 Highway-rail collision/impact Texas Eagle Leeper MO 0 Total Sleeper 63 59 
166

Table 14. Amtrak Accidents Resulting in Passenger Injury/Fatality 

Reserved Trains

Year Month Day Event Train Name Location St

Passengers 

Killed 

Pa

I

1993 June 28 Highway-rail collision/impact State House Alton IL 0 1993 August 24 Highway-rail collision/impact Lake Cities Kalamazoo MI 0 1994 June 6 Highway-rail collision/impact International Kalamazoo MI 0 1995 September 6 Highway-rail collision/impact San Joaquin Merced CA 0 1997 August 31 Highway-rail collision/impact San Joaquin Madera CA 0 1997 September 15 Highway-rail collision/impact Pere Marquette Gary IN 0 1998 June 18 Highway-rail collision/impact Carolinian Durham NC 0 1998 September 29 Highway-rail collision/impact State House Wilmington IL 0 1998 November 5 Highway-rail collision/impact San Joaquin Pittsburg CA 0 1999 August 30 Highway-rail collision/impact San Joaquin Fresno CA 0 2000 August 27 Derailment San Joaquin Fresno CA 0 2001 February 5 Collision-between on track equipment Empire Syracuse NY 0 2001 May 4 Highway-rail collision/impact San Joaquin Planada CA 0 2001 August 30 Highway-rail collision/impact Illini Centralia IL 0 2002 April 10 Derailment Kentucky Cardinal Jeffersonville IN 0 2002 May 26 Highway-rail collision/impact Illini Danforth IL 0 2002 June 4 Collision/impact-auto, truck, bus, etc. San Joaquin Wasco CA 0 2002 September 5 Highway-rail collision/impact Cascade Everett WA 0 2003 March 27 Highway-rail collision/impact San Joaquin Fresno CA 0 Total Reserved 19 0 
167

Table 15. Amtrak Accidents Resulting in Passenger Injury/Fatality 

Unreserved Trains

Year Month Day Event Train Name Location St

Passengers 

Killed

Pa

I

1993 January 1 Highway-rail collision/impact Pacific Surfliner Ponto CA 0 1997 February 20 Highway-rail collision/impact Pacific Surfliner San Juan Capistrano CA 0 2000 November 4 Highway-rail collision/impact Pacific Surfliner Moorpark CA 0 2001 November 23 Highway-rail collision/impact Pacific Surfliner Camarillo CA 0 2002 September 28 Collision/impact-auto, truck, etc. Pacific Surfliner San Juan Capistrano CA 0 2003 December 14 Struck object on tracks Capital Rodeo CA 0 Total Unreserved 6 0 

Table 16. Amtrak Accidents Resulting in Passenger Injury/Fatality 

Unknown Train Type

Year Month Day Event Train Name Location St

Passengers 

Killed

Pa

I

1993 November 23 Derailment Unknown Boise ID 0 1994 April 15 Collision-between on track equipment Unknown Old Saybrook CT 0 1997 January 13 Derailment Unknown Granite WY 0 1996 November 23 Derailment Unknown Newark NJ 0 Total Unknown 4 0 

169

Appendix G. Amtrak Route Characteristics by Route 

Table 17. Selected Characteristics–Overnight/Sleeper Routes 

Route 

Number Route Name Ridership Percent 

Trains/Week 

(Both Ways) Percent 

06 

Federal (Twilight 

Shoreliner)5 168,362 0.7% 14 0.8%

16 Silver Star 262,753 1.1% 14 0.8%

17 Three Rivers 146,739 0.6% 14 0.8%

18 Cardinal 78,942 0.3% 6 0.3%

19 Silver Meteor 300,687 1.3% 14 0.8%

25 Empire Builder 440,891 1.9% 14 0.8%

26 Capitol Limited 168,523 0.7% 14 0.8%

27 California Zephyr 341,770 1.5% 14 0.8%

28 Southwest Chief 289,852 1.2% 14 0.8%

30 City of New Orleans 191,361 0.8% 14 0.8%

32 Texas Eagle 230,246 1.0% 14 0.8%

33 Sunset Limited 112,006 0.5% 6 0.3%

34 Coast Starlight 456,269 1.9% 14 0.8%

45 Lake Shore Limited 276,397 1.2% 14 0.8%

52 Crescent 263,875 1.1% 14 0.8%

63 Auto Train 199,804 0.9% 14 0.8%

Total 3,928,477 16.7% 208 11.4%

All data are for 2003

 

5

 In 2004, the Federal was replaced by an all reserved Regional without sleeper service. 
170

Table 18. Selected Characteristics–Reserved Routes 

Route 

Number Route Name Ridership Percent 

Trains/Week 

(Both Ways) Percent 

1 Metroliner/Acela Express 3,002,451 12.8% 214 11.8%

4 Vermonter 258,899 1.1% 14 0.8%

9 Downeaster 257,801 1.1% 8 0.4%

20 Chicago-St. Louis 106,284 0.5% 28 1.5%

22 Chicago-Pontiac 344,107 1.5% 42 2.3%

23 Illini 105,879 0.5% 14 0.8%

24 Illinois Zephyr 107,250 0.5% 14 0.8%

29 Heartland Flyer 49,033 0.2% 14 0.8%

36 Cascades 589,913 2.5% 70 3.8%

39 San Joaquins 783,096 3.3% 84 4.6%

40 Adirondack 131,250 0.6% 14 0.8%

41 International 83,530 0.4% 14 0.8%

48 Palmetto (Silver Palm) 204,577 0.9% 14 0.8%

54 

Hoosier State (Kentucky 

Cardinal) 19,248 0.1% 14 0.8%

56 Kansas City-St. Louis 239,429 1.0% 28 1.5%

65 Pere Marquette 75,606 0.3% 14 0.8%

66 Carolinian 323,481 1.4% 14 0.8%

67 Piedmont 41,310 0.2% 14 0.8%

Total 6,723,144 28.7% 628 34.5%

All data are for 2003
171

Table 19. Selected Characteristics–Unreserved Routes 

Route 

Number Route Name Ridership Percent 

Trains/Week 

(Both Ways) Percent 

13 Clocker Service 1,553,696 6.6% 36 2.0%

14 Keystone 1,250,345 5.3% 106 5.8%

21 Hiawathas 424,318 1.8% 96 5.3%

35 Pacific Surfliner 2,228,042 9.5% 162 8.9%

37 Capitols 190,110 0.8% 156 8.6%

57 Pennsylvanian 148,841 0.6% 14 0.8%

Total 5,795,352 24.7% 570 31.3%

All data are for 2003

Table 20. Selected Characteristics–Mixed Reserved/Unreserved Routes6

Route 

Number Route Name Ridership Percent

Trains/Week 

(Both Ways) Percent

5 

Unreserved NE Direct/Acela 

Regional 4,800,953 20.5% 219 12.0%

5 

Reserved NE Direct/Acela 

Regional 1,052,264 4.5% 48 2.6%

3 Ethan Allen Express 109,858 0.5% 14 0.8%

7 Maple Leaf 174,958 0.7% 14 0.8%

15 Unreserved Empire Service 704,464 3.0% 92 5.1%

15 

Reserved/Mixed Empire 

Service 167,234 0.7% 28 1.5%

Total 7,009,731 29.9% 415 22.8%

All data are for 2003

 

6 NE Direct/Acela Regional operates a mix of reserved/unreserved trains. In 2003, 18 percent of trains were 

reserved. 

The Ethan Allen Express is reserved north of Albany. In year 2003, 32.5 percent of traffic was reserved. 

The Maple Leaf currently operates as an unreserved train from New York to Albany and as a reserved train from 

Albany to Toronto. In year 2003, 75.4 percent of traffic was reserved. 

Only two Empire trains/day operate from New York to Niagara Falls. About 6-7 trains/day operate from New York 

to Albany. All trains are unreserved from New York to Albany. Two trains operate as reserved trains from Albany 

to Niagara Falls. In year 2003, 19.2 percent of traffic was reserved. 
172

Table 21. Staffed/Unstaffed Amtrak Stations–Sleeper Routes 

Route Stations Served 

Number Name Total Staffed Percent Unstaffed Percent

06 Federal7 20 20 100% 0 0%

16 Silver Star 33 24 73% 9 27%

17 Three Rivers 20 11 55% 9 45%

18 Cardinal 34 16 47% 18 53%

19 Silver Meteor 33 24 73% 9 27%

25 Empire Builder 45 24 53% 21 47%

26 Capitol Limited 15 6 40% 9 60%

27 California Zephyr 35 17 49% 18 51%

28 Southwest Chief 32 15 47% 17 53%

30 City of New Orleans 19 8 42% 11 58%

32 Texas Eagle 40 18 45% 22 55%

33 Sunset Limited 40 10 25% 30 75%

34 Coast Starlight 29 20 69% 9 31%

45 Lake Shore Limited 25 15 60% 10 40%

52 Crescent 32 18 56% 14 44%

63 Auto Train 2 2 100% 0 0%

 

7

 In 2004, the Federal was replaced by an all reserved Regional without sleeper service. 
173

Table 22. Staffed/Unstaffed Amtrak Stations–Reserved Routes 

Route Stations Served 

Number Name TotalStaffedPercent Unstaffed Percent

01 Metroliner/Acela Express 18 18 100% 0 0%

04 Vermonter 26 15 58% 11 42%

09 Downeaster 9 2 22% 7 78%

20 Chicago-St. Louis 11 6 55% 5 45%

23 Chicago-Pontiac 15 8 53% 7 47%

23 Illini 11 4 36% 7 64%

24 Illinois Zephyr 10 3 30% 7 70%

29 Heartland Flyer 7 1 14% 6 86%

36 Cascades 16 12 75% 4 25%

39 San Joaquins 16 9 56% 7 44%

40 Adirondack 19 10 53% 9 47%

41 International 20 7 35% 13 65%

48 Palmetto (Silver Palm) 35 26 74% 9 26%

54 Hoosier State (Kentucky Cardinal) 6 2 33% 4 67%

56 Kansas City-St. Louis 20 7 35% 13 65%

65 Pere Marquette 6 1 17% 5 83%

66 Carolinian 25 17 68% 8 32%

67 Piedmont 8 4 50% 4 50%

Table 23. Staffed/Unstaffed Amtrak Stations–Mixed Reserved/Unreserved Routes 

Stations Served 

Route Number Name Total Staffed Percent Unstaffed Percent

03 Ethan Allen Express 12 8 67% 4 33%

05 NE Direct/Acela Regional 35 27 77% 8 23%

07 Maple Leaf 22 17 77% 5 23%

15 Empire Service 16 13 81% 3 19%
174

Table 24. Passenger Boardings by Station Type–Sleeper Routes 

Route Passenger Boardings 

Number Name Total Staffed Percent Unstaffed Percent 

06 Federal8 168,362 168,362 100% 0 0%

16 Silver Star 262,753 240,332 91% 22,421 9%

17 Three Rivers 146,739 131,469 90% 15,270 10%

18 Cardinal 78,942 61,483 78% 17,459 22%

19 Silver Meteor 300,687 271,532 90% 29,155 10%

25 Empire Builder 440,891 388,898 88% 51,993 12%

26 Capitol Limited 168,523 150,932 90% 17,591 10%

27 California Zephyr 341,770 304,575 89% 37,195 11%

28 Southwest Chief 289,852 246,165 85% 43,687 15%

30 City of New Orleans 191,361 169,361 89% 22,000 11%

32 Texas Eagle 230,246 214,881 93% 15,365 7%

33 Sunset Limited 112,006 92,196 82% 19,810 18%

34 Coast Starlight 456,269 424,521 93% 31,748 7%

45 Lake Shore Limited 276,397 261,619 95% 14,778 5%

52 Crescent 263,875 235,833 89% 28,042 11%

63 Auto Train 199,804 199,804 100% 0 0%

 Total 3,928,477 3,561,965 91% 366,512 9%

 

8

 In 2004, the Federal was replaced by an all reserved Regional without sleeper service. 
175

Table 25. Passenger Boardings by Station Type–Reserved Routes 

Route Passenger Boardings 

Number Name Total Staffed Percent Unstaffed Percent

01 Metroliner/Acela Express 3,002,451 3,002,451 100% 0 0%

04 Vermonter 258,899 229,003 88% 29,896 12%

09 Downeaster 257,801 184,988 72% 72,813 28%

20 Chicago-St. Louis 106,284 98,704 93% 7,580 7%

23 Chicago-Pontiac 344,107 320,659 93% 23,448 7%

23 Illini 105,879 91,552 86% 14,327 14%

24 Illinois Zephyr 107,250 60,084 56% 47,166 44%

29 Heartland Flyer 49,033 19,091 39% 29,942 61%

36 Cascades 589,913 554,117 94% 35,796 6%

39 San Joaquins 783,096 724,991 93% 58,105 7%

40 Adirondack 131,250 116,916 89% 14,334 11%

41 International 83,530 59,449 71% 24,081 29%

48 Palmetto (Silver Palm) 204,577 189,804 93% 14,773 7%

54 

Hoosier State (Kentucky 

Cardinal) 19,248 15,949 83% 3,299 17%

56 Kansas City-St. Louis 239,429 155,125 65% 84,304 35%

65 Pere Marquette 75,606 37,228 49% 38,378 51%

66 Carolinian 323,481 294,245 91% 29,236 9%

67 Piedmont 41,310 34,107 83% 7,203 17%

 Total 6,723,144 6,188,464 92% 534,680 8%

Table 26. Passenger Boardings by Station Type–Partially Reserved Routes 

Route Passenger Boardings 

Number Name Total Staffed Percent Unstaffed Percent 

03 Ethan Allen Express 109,858 96,528 88% 13,330 12%

05 

NE Direct/Acela 

Regional 5,853,217 5,806,114 99% 47,103 1%

07 Maple Leaf 174,958 169,382 97% 5,576 3%

15 Empire Service 871,698 810,287 93% 61,411 7%

 Total 7,009,731 6,882,310 98% 127,421 2%
176

Table 27. Station Intervals (in miles)–Sleeper Routes 

Route All Stations Staffed Stations Only

Number Name Average Maximum Average Maximum

06 Federal9 24.1 69 24.1 69

16 Silver Star 43.4 106 60.4 203

17 Three Rivers 47.8 137 90.8 464

18 Cardinal 34.7 69 76.4 279

19 Silver Meteor 43.4 109 63.1 196

25 Empire Builder 58.8 148 112.4 296

26 Capitol Limited 54.6 88 152.8 283

27 California Zephyr 71.7 263 152.4 594

28 Southwest Chief 72.8 173 173.5 493

30 City of New Orleans 51.4 124 132.3 221

32 Texas Eagle 69.9 218 160.5 604

33 Sunset Limited 70.9 218 345.5 622

34 Coast Starlight 49.6 121 73.1 324

45 Lake Shore Limited 48.3 108 82.7 187

52 Crescent 44.4 100 81.0 202

63 Auto Train 855.0 855 855.0 855

 

9

 In 2004, the Federal was replaced by an all reserved Regional without sleeper service. 
177

Table 28. Station Intervals (in miles)–Reserved Routes 

Route All Stations Staffed Stations Only

Number Name Average Maximum Average Maximum

01 Metroliner/Acela Express 26.9 69 26.9 69

04 Vermonter 24.2 68 40.4 251

09 Downeaster 14.5 34 116.0 116

20 Chicago-St. Louis 28.4 39 56.8 87

23 Chicago-Pontiac 21.7 38 38.0 89

23 Illini 31.0 53 103.3 181

24 Illinois Zephyr 28.7 56 86.0 134

29 Heartland Flyer 34.3 65 206.0 206

36 Cascades 31.1 58 42.4 82

39 San Joaquins 24.2 48 40.3 81

40 Adirondack 21.2 45 42.3 199

41 International 26.4 89 83.7 161

48 Palmetto (Silver Palm) 40.9 143 55.6 143

54 

Hoosier State (Kentucky 

Cardinal) 39.2 65 196.0 196

56 Kansas City-St. Louis 29.8 64 94.5 283

65 Pere Marquette 35.2 61 176.0 176

66 Carolinian 29.3 98 44.0 114

67 Piedmont 24.7 47 57.7 89

Table 29. Station Intervals (in miles)–Partially Reserved Routes 

Route All Stations Staffed Stations Only

Number Name Average Maximum Average Maximum

03 Ethan Allen Express 21.9 40 30.1 63

05 NE Direct/Acela Regional 18.9 55 24.8 101

07 Maple Leaf 26.0 80 34.1 80

15 Empire Service 30.7 80 38.4 80

179

Appendix H. Cost Estimate Assumptions for System Improvements 

H.1 General Cost Considerations 

In general, introducing any automated ticket collection system, including those proposed in 

Section 7 of this report, will include many, if not all, of the following types of cost elements: 

• System design and development effort (i.e., staff and/or consultant time), including 

specifications for equipment, and ticket media 

• Procurement and installation of fare collection and dispensing equipment and related 

software (e.g., card accepting devices and application software and card dispensing 

machines) 

• Procurement and installation of station- and central-computer system (including 

software) 

• Installation or modification of the communications infrastructure and system 

• Purchase or production of fare media 

• Day-to-day administration 

• Maintenance and repair 

• Marketing (promotion and education of customers) 

• Sales and distribution 

• Revenue accounting 

• Training (e.g., maintenance, operations, customer service, and revenue and finance)10

Fare collection equipment tends to be a customized product. No typical cost exists; rather, a 

range of costs can be estimated, keeping in mind that many conditions and assumptions may be 

involved in the estimate. Unit costs are generally developed for each type of equipment based on 

the supplier quotations, equipment characteristics, experience with recent purchases, and 

appropriate multipliers to allow for economies of scale and escalation for the time value of 

money. In addition, costs for engineering and support services depend on the purchasing 

experience of the agency, the local contracting environment, and the skills available within the 

agency’s personnel—and whether the agency is purchasing this type of equipment for the first 

time or it is a new generation replacing old equipment. It should also be kept in mind that in 

many cases, fare collection equipment is largely built in response to individual orders. Each 

agency’s requirements invariably impose different performance features, even if major modules 

or subassemblies are the same among several orders. Final configurations of even very similar 

equipment for different agencies are rarely alike. 

The price for any type of equipment is therefore sensitive to such factors as the following: 

 

10 Fleishman, Daniel, Multipurpose Transit Payment Media, T C R P Report 32, Transportation Research Board, 

National Research Council, National Academy Press, Washington, DC, 1998. 
180

• The equipment specifications for the individual agency, including performance 

requirements and features; this affects the amount of customization required for a 

product, and this customization can represent a substantial portion of the overall price. 

• The quantities of the particular equipment being ordered. 

• The extent to which the new equipment will have to interface with existing equipment 

(i.e., that is not being replaced). 

• The nature of the vendor selection and negotiation process (e.g., type of contract: low 

bid, two step, or negotiated). 

• The timing of the procurement (relative to the procurement of similar equipment by other 

agencies and therefore the extent of refinement of the technology). 

• Growth potential (e.g., opportunities for new/extended lines). 

• Warranty terms: warranties are generally for 1 year, but this period can be extended 

based on other clauses associated with equipment performance. 

• Documentation requirements (i.e., striking a balance between what is offered as 

manufacturer’s standard and degree of customization for the agency). 

• Software requirements: some software customization is expected, but requests for 

additional functions, features, and reports will be considered extra and will increase the 

cost. 

• Vehicle/station/facility modifications: the cost of modifications to vehicles, stations, or 

other facilities must also be considered. 

• Americans with Disabilities Act (ADA) requirements: fare collection equipment must 

address ADA requirements; these include accommodation of wheelchairs in turnstiles, 

compliance with height requirements for buttons on automated vending machines, and 

accommodation of needs of blind riders in purchasing and using fare media.11

Cost components for the various alternative systems considered would include: 

Vehicle-Related Costs 

Stand-alone smart card processing unit 

Application software (smart card units) 

Data communications system to/from train 

Onboard computer hardware and software 

Portable (handheld ) ticket scanner with ticket issue capability 

Station-Related Costs 

Ticket vending machine (TVM) 

Booking office machines (BOM) 

Bidirectional fare gate (contactless card) 

Station hardware/software 

Central hardware/software 

Communications infrastructure linking station computers and CNOC 

 

11 Fare Policies, Structures and Technologies: Update, T C R P Report 94, Transportation Research Board, 

National Research Council, National Academy Press, Washington, DC, 2003.
181

Variable System Costs 

Spare Parts 

Support services, including training, documentation, revenue testing, and warranties 

Installation 

Nonrecurring engineering and software costs (equipment development and testing) 

Contingency 

Equipment maintenance costs (labor and material, shop facilities, and vehicle fleet for 

maintainers) 

Software licenses/system support 

Revenue handling costs 

Fare Media Costs 

Contactless cards (paper) 

Other ticket media 

Section 7 indicated the specific cost components for each of the alternative systems considered, 

and the cost estimates were based on the information in this appendix. 

H.2 Estimated Quantities 

Quantities of the various components used in each of the alternative systems were estimated 

using the methods described below. 

Onboard Door Readers–Amtrak operates 2,141 railroad cars, including 168 sleeper cars, 760 

coach cars, 126 first class/business class cars, 66 dormitory crew cars, 225 lounge/café/dinette 

cars, and 92 dining cars. Baggage cars make up the remainder of the fleet.12 Of this fleet it is 

assumed that 1,054 cars (168 sleeper cars, 760 coach cars, and 126 first class/business class cars) 

would be equipped with door readers. Passengers would not board through dormitory crew cars, 

lounge/café/dinette cars, or dining cars. This figure represents an upper bound on the number of 

cars that must be equipped with door readers since all of the coach cars are not used on reserved 

trains. It was not possible, however, to determine whether coach cars were permanently assigned 

to specific reserved or unreserved trains, and Amtrak might decide to adopt many elements of a 

new system for the unreserved trains. 

It was assumed that each car would be equipped with two readers. Sleeper cars, coach cars, and 

first class/business class cars have either two or four doors for passenger boarding exclusive of 

the doors at each end, which allow passage from one car to another.13 On those cars having four 

doors, passenger boarding would have to be restricted to doors equipped with readers, or 

additional costs incurred to equip all doors. This results in an estimated requirement for 2,108 

door readers. 

 

12 Inside Amtrak, Government Affairs, Amtrak Facts, http://www.amtrak.com. 

13 Superliner I, Superliner II, and Viewliner sleepers have two doors per car. Superliner I, Superliner II, Talgo, 

Heritage, and Amfleet II coaches have two doors per car, while Horizon, California, Amfleet I, and Metroliner 

coaches have four doors per car. Talgo and Acela Express first class/business class cars have two doors per car, 

while other Acela Express first class/business class cars have four doors per car. 
182

Onboard Computers and Communication Devices–In 2003, Amtrak operated 265 trains per day 

on average. It was assumed that Amtrak would not maintain separate ticketing systems for 

reserved and unreserved trains. Each alternative was assumed to be implemented system-wide. 

It was assumed that each train would be equipped with an onboard computer and a data 

communications system. With a 10 percent spares allowance this results in an estimated 

minimum requirement for 291 onboard computers and train-to-station data communications 

systems. This assumes portable equipment and that each of 336 lounge/café/dinette/dining cars 

(including Acela trainsets) is outfitted with a docking station for the portable equipment. All of 

Amtrak’s reserved (and many unreserved) trains operate with one or more of these cars. 

If built-in computer and train-to-station data communications systems are assumed, then each of 

the 336 lounge/café/dinette/dining cars would have to be equipped. This is necessary to ensure 

that trains would not be cancelled because of a malfunction, such as air conditioning, in the car 

containing the built-in computer. If built-in computer and train-to-station data communications 

systems are assumed, a need to modify cars may exist to provide for a conductor’s office area. 

For systems based on satellite/cellular communications technology, it was assumed that each 

Amtrak locomotive would be equipped with the train-to-CNOC data communications system. 

This is to provide the system redundancy noted above. Satellite/cellular communications 

technology would most likely require a locomotive mounted exterior antenna. Amtrak operates 

425 locomotives and 19 Acela trainsets14 for a requirement of 444 satellite/cellular 

communications systems. 

Handheld Ticket Scanning/Issuing Devices–Trains of more than seven revenue cars require three 

conductors; those with less than seven cars generally have two but could have three under certain 

circumstances, such as close station spacing or heavy traffic loads.15 

Information on individual train staffing was not available. It was assumed that there would be an 

average of 2.5 conductors for each of 265 trains each day. This would lead to a requirement for 

662 handheld devices for scanning and issuing tickets on board. With a 10 percent allowance for 

spares, the requirement becomes 728 handheld devices. If instead each Amtrak conductor were 

issued a handheld device, even more would be required, so this is a conservative estimate. 

Station Computers and Station-to-Train Communication Devices–Amtrak provides service at 

211 staffed stations and 304 unstaffed stations with reserved and unreserved trains. This 

indicates a need for 515 station computers and 515 train-to-station communication devices. 

Ticket Vending Machines–Of the staffed stations, 55 also have a Quik-Trak TVM, while 17 

unstaffed stations are equipped with a Quik-Trak TVM. It was assumed that all stations having a 

Quik-Trak would also have a TVM under the proposed alternative system. In addition, all 

 

14 Inside Amtrak, Government Affairs, Amtrak Facts, http://www.amtrak.com. 

15 Telephone conversation with Dave Nogard, Amtrak, April 5, 2004. 
183

unstaffed stations would have a TVM under two of the alternatives. This leads to a requirement 

for 359 TVMs. 

Passenger boarding volumes at unstaffed stations currently without a TVM range from 23,500 

per year (64 per day) to 65 per year (less than 1 per day). Passenger boarding volumes at 

unstaffed stations currently with a TVM range from 21,180 per year (58 per day) to 2,390 per 

year (7 per day). Using this last figure as the minimum passenger volume for a TVM at an 

unstaffed station reduces the requirement for TVMs by 162 to 197. However, these 162 

unstaffed station locations would have to be provided with a means of issuing tickets to 

passengers before boarding. This could be accomplished by establishing arrangements with 

local banks or retail establishments to issue Amtrak tickets on a commission basis. These 

establishments would have to be provided with a type of BOM for recording reservation and 

payment information and issuing tickets. 

Booking Office Machines–All currently staffed stations would also have to be provided with new 

BOMs for issuing the new type of tickets. It was assumed that requirements for ticket windows 

and BOMs would vary as a function on passenger boardings per day. An average transaction 

time of 2 minutes was assumed.16 This resulted in the following guidelines for estimating 

purposes: 

< 240 passengers per day - 1 window 

241–480 passengers per day - 2 windows 

481–720 passengers per day - 3 windows 

721–960 passengers per day - 4 windows 

961–1200 passengers per day - 5 windows 

> 1200 passengers per day - 6 windows 

Applying these criteria to the average daily station boarding volumes for currently staffed 

stations results in a requirement for 310 BOMs (169 stations with 1 window, 21 stations with 2 

windows, 5 stations with 3 windows, 4 stations with 4 windows, 4 stations with 5 windows, and 

8 stations with 6 windows). 

Ticket Reading Gates–Gate requirements at staffed stations were estimated based on the average 

boarding volume per train for the route having the maximum boarding volume per train at each 

individual station and an assumed gate throughput rate. Passenger boarding volumes per train at 

staffed stations range from 2 to 573. The gate throughput rate assumed was 20 passengers per 

minute.17 It was assumed that passengers would be prohibited from passing through the gates 

 

16 The Ernst & Whitney study for New Jersey Transit Corporation provided data on ticket sales per station and 

number of ticket agents per station for a commuter rail operation. This data indicated that a single ticket window 

was capable of handling up to 400 ticket sales per day. It was assumed that these transactions would be relatively 

simple in comparison to the typical Amtrak ticket sale; thus a reduced processing rate was used for this analysis. 

17 Jeffreys, Dennis C., et al., Evaluation of Automatic Fare Collection Technology–Volume II–Technology 

Assessment, prepared for New York Metropolitan Transportation Authority, Arthur D. Little, Inc., Cambridge, 

September 1984, p.4-1. 
184

and entering the platform area until 5 minutes before the train’s arrival. To provide a measure of 

redundancy in the event of gate malfunction, it was further assumed that the minimum number of 

gates per station would be two. 

Applying these assumptions to the boarding volumes per train for currently staffed stations 

results in a requirement for 443 gates (198 stations with 2 gates, 8 stations with 3 gates, 4 

stations with 4 gates, and 1 station with 7 gates). 

Station Modifications–To estimate the cost of station modifications required to accommodate a 

gated system at all currently staffed stations, stations were classified either as high, moderate, or 

low cost stations. This classification was based on daily passenger volumes. It was assumed that 

stations with less than 100 passengers/day (135 stations) would require low cost modifications, 

stations with 100 to 500 passengers per day (56 stations) would require moderate cost 

modifications, and stations with over 500 passengers per day (20 stations) would require high 

cost modifications. 

Ticket Stock–The estimated number of smart card tickets required was based on Amtrak’s annual 

ridership in 2003. Amtrak carried approximately 24,000,000 passengers in 2003.18 It was 

assumed that this figure includes revenue and non-revenue passengers, although it was not 

possible to determine this from the detailed ridership data. It was also assumed that most 

passengers made a round trip, thus implying the need for about 24,000,000 one-way or 

approximately 12,000,000 round-trip smart card/tickets. 

The annual ridership figures, however, include Amtrak monthly and multiride passholders. The 

following Amtrak Routes offer Multi-ride Ticketing Options: Regional (reserved and 

unreserved), Clocker Service (unreserved), Keystone Service (unreserved), Downeaster 

(reserved), Empire Service (unreserved), Wolverine (reserved), Ann Rutledge (reserved), 

Missouri Mules (reserved), State House (reserved), Hiawatha (unreserved), Cascades (reserved), 

San Joaquin (reserved), Capitol Corridor (unreserved), and Surfliner (unreserved). 

The number of monthly passes issued per year used on these routes was assumed to equal the 

number of monthly pass holders times 12. The number of monthly pass holders was estimated as 

the ridership on each route that was listed as other divided by 2 (round trips/year) divided by 12 

(round trips/month) divided by 20 (round trips/day). While other generally accounts for data 

processing errors in the train-specific, origin/destination data, experience indicates that Amtrak 

accounts for passholders in this category. For example, 332,000 out of 2,228,000 one-way trips 

(15 percent) fall into the other category on the Pacific Surfliners. In total (based on the other 

figures for all services on which Amtrak passes can be used), it was estimated that 830,000 oneway trips were made by passholders, resulting in an estimated need for 21,000 smart card passes 

per year. These figures were used to reduce the number of single-use tickets required. 

 The report noted that, while the Japanese have achieved rates of up to 65 to 75 passengers per minute per 

gate with smart cards, ADL was using a rate of 25 passengers per minute per gate to allow for out-ofservice equipment. This was further reduced for this analysis to allow for the added impedance of 

accommodating passengers with luggage. 

18 Inside Amtrak, Government Affairs, Amtrak Facts, http://www.amtrak.com. 
185

The final estimated requirement for smart card tickets was estimated as 23,170,000 one-way 

smart card tickets per year or 11,585,000 round-trip smart card tickets per with an additional 

21,000 smart card passes per year in either case. 

H.3 Unit Costs 

Unit costs used in the order of magnitude cost estimates for each alternative system described in 

the following section were based on those available in the literature. Much of this work is 

derived from urban transit system applications of automatic fare collection technology and other 

Intelligent Transportation Systems Applications (ITS), as well as historical commuter rail 

operations.19 Equipment, such as station computers, ticket readers, and gates, would be similar 

to those that would be used in an Amtrak application. Costs for station modifications needed to 

accommodate a gated entry/exit system were taken from a feasibility study for an automatic fare 

collection system for New York’s Metropolitan Transportation Authority, which considered a 

gated entry/exit system for the Long Island Railroad and Metro North Commuter Railroad.20

Historic costs were adjusted to 2004 dollars using various industry and commodity components 

of the Bureau of Labor Statistics’ Producers’ Price Index.21

 

19 Balaban, Dan, “Wave of the Future?”, Card Technology, January 2002, p.18. 

Burger, Todd O., et al., Evaluation of Automatic Fare Collection Technology–Volume IIIB–Evaluation of System 

Concepts: Commuter Rail, prepared for New York Metropolitan Transportation Authority, Arthur D. Little, Inc., 

Cambridge, Massachusetts, November 1984. 

Bushnell, William R., Smart Cards for Transit: Multi-Use Remotely Interrogated Stored-Data Cards for Fare and 

Toll Payment, Report FTA-MA-26-0020-95-1, prepared for Federal Transit Administration, Volpe National 

Transportation Systems Center, Cambridge, Massachusetts, April 1995. 

Commuter Rail Fare Collection, A Comprehensive Strategy for Improvements, prepared for New Jersey Transit 

Corporation, Ernst & Whitney, December 1982. 

Fare Policies, Structures and Technologies: Update, TCRP Report 94, Transportation Research Board, National 

Research Council, National Academy Press, Washington, DC, 2003. 

TTC Fare Collection Study, Toronto Transit Commission, October 2000. 

http://www.benefitcost.its.dot.gov/ITS/benecost.nsf. 

20 Grenzeback, Lance R., and Tomasz M. Wiktor, Evaluation of Automatic Fare Collection Technology–Volume 

IVB–Station and Vehicle Modifications: Commuter Rail, prepared for New York Metropolitan Transportation 

Authority, Arthur D. Little, Inc., Cambridge, Massachusetts, November 1984. 

21 The indices used included communication and related equipment (WPU1176), electronic components and 

accessories (WPU1178), applications software (PCU5112105112102), non-residential buildings (PCUBBLD), and 

electronic computers and computer equipment (WPU115). http://www.bls.gov/data/home.htm. 
186

Table H-1 indicates unit costs for the various system components. These costs were applied to 

the quantities noted in the previous section to develop capital and annual operating cost estimates 

for each of the alternatives considered in Section 7. 
187

Table 30. Unit Costs, 2004 Dollars 

 

Cost Element Cost (dollars) Nature of Cost 

Low High One-Time Ongoing 

Stand-alone smart card processing unit 1,000 6,800 X 

Central computer facility equipment–hardware 

with backup 

 1,024,500 X 

Central computer and station software 

(proprietary) c/w design and development 

 1,734,400 X 

Station hardware/software per station 6,400 9,200 X 

System integration, communications equipment, 

and data lines network per station 

 13,200 X 

TVM 29,000 58,100 X 

Fare gate (magnetic/contactless card) 19,400 33,900 X 

Booking Office Machine 11,800 

Portable (handheld ) smart card validator 1,900 3,900 X 

Station preparation cost–does not include the cost 

of the gates 

 

High cost station 1,037,100 X 

Moderate cost station 581,200 X 

Low cost station 185,500 X 

Encoded paper fare media 0.02 0.04 X 

Contactless cards (paper) 0.3 1 X 

Variable System Costs 

Spare Parts (% of equipment cost) 10 15 X 

Support services, including training, 

documentation, revenue testing, and warranties 

(% of equipment cost) 

10 15 X 

Installation (% of equipment cost) 3 10 X 

Nonrecurring engineering and software costs (% 

of equipment cost) 

0 30 X 

Contingency (% of equipment/operating cost) 10 15 X X 

Equipment maintenance costs (% of equipment 

cost) 

5 7 X 

Software licenses/system support (% of 

systems/software cost) 

15 20 X 

Revenue handling costs (% of annual cash 

revenue) 

5 10 X 

189

APPENDIX I. Excerpts from Amtrak’s FY 2005–2009 Strategic Plan22

Transportation–Support Systems–Program Goals 

A major focus of Amtrak’s capital plan is to provide real-time train status information 

throughout Amtrak operations. Enhancements to existing systems and the purchase of new 

technologies will increase accuracy and provide operating personnel and passengers with better 

information on the status of trains and services. Communications with trains, identification of 

equipment locations, and adherence to schedules will be implemented using GPS technology. 

This will allow CNOC to monitor train status and communicate directly with train crew and 

passengers. 

Transportation–Support Systems–Project List 

Arrow Enhancements for Transportation–Improvements to Arrow/reservation system to increase 

accuracy of train time reporting, allow creation of new train schedule displays, make seats 

available for sale immediately, provide better equipment and inventory management, and 

increase accuracy of train manifests. 

Train Communications Project–Provide state of the art system for real-time communications 

with trains. 

Marketing and Sales–Program Goals 

The Marketing and Sales department is challenged with antiquated hardware and software 

platforms and out-of-date ticketing processes. Many mission critical systems are at the end of 

their useful life cycle. Equipment failures and downtime are increasing, and potential 

efficiencies from new technology are unrealized. 

The State of Good Repair program replaces and upgrades aging distribution channel 

infrastructure and will reduce failures and improve efficiency. The program will implement call 

center labor tracking, replace telephony infrastructure, directly connect travel agents to the 

booking system, reduce travel agency costs, and expand voice response capabilities. 

The FY05 to FY09 capital plan upgrades and modernizes the sales process by investing in eticketing, creating opportunities for targeted marketing, and creating user friendly graphical 

interfaces. These projects will reduce expenses, increase revenue opportunities, and improve 

customer service through improved response time and customer handling. 

 

22 Amtrak Strategic Plan FY 2005-2009, June 29,2004. 
190

Marketing and Sales–Project List 

E-Ticketing–Replace the ticket lift process with boarding pass/seat check system. Revenue 

recognition occurs at issuance, reducing back-office costs, and improving manifest accuracy.

Internet: Customized Access–Creates a new Web site that will allow travel agents to book 

directly with Amtrak, replacing obsolete travel agent reservation systems, and thus substantially 

reducing $ 5.5 million in annual systems contract expenses. 

Reservation System Enhancements–Replaces existing, older generation system interface (c. 

1998) with a new graphical user interface for Call Centers and Station Agents that will reduce 

training costs and improve customer service. 

Centralized Customer Database(s)–Replaces multiple, disconnected databases with a centralized 

data store to support all sales-related functions.