Passenger Trains > NTSB view of Amtrak/NS 07 collision

NTSB delivered its report on the November 2007 collision between an Amtrak train and an NS freight near Englewood interlocking in Chicago.

NTSB DETERMINED ENGINEER'S INACCURATE INTERPRETATION OF SIGNAL LED TO CAUSE OF AN AMTRAK ACCIDENT IN CHICAGO

Washington, D.C., - The National Transportation Safety Board today determined that the probable cause of a collision of an Amtrak (National Railroad Passenger Corporation) train with the rear of a Norfolk Southern Railway Company (Norfolk Southern) train was the failure of the Amtrak engineer to correctly interpret the signal at Englewood interlocking and Amtrak's failure to ensure that the engineer had the competency to correctly interpret the signal across the different territories over which he operated.

"As we discovered in this accident investigation, the comprehensive training and evaluation of the train crews is extremely critical," said NTSB Acting Chairman Mark V. Rosenker. "Ensuring that we have the most qualified and prepared crew at the controls can prevent accidents like this from occurring."

On Friday, November 30, 2007, about 11:23 a.m., CST, Amtrak passenger train 371, consisting of one locomotive and three passenger cars, struck the rear of standing Norfolk Southern freight train 23M. The forward portion of the Amtrak locomotive came to rest on top of a container on the rear car of the freight train. Sixty-six passengers and 5 crew members were transported to hospitals; 2 passengers and 1 crew member were admitted.

In today's report, the Safety Board found that as the Amtrak train traveled closer to the first signal at Englewood interlocking, the engineer made a significant error when he misinterpreted the meaning of the red over yellow signal aspect. The red over yellow aspect was a restricting indication that required the crew to operate the train at a maximum speed of 15 mph and to be prepared to stop for any trains or obstructions ahead.

The report states that the engineer misinterpreted the signal as a slow approach, which would have allowed him to operate at a maximum speed of 30 mph while being prepared to stop at the next signal. It is important to note that a slow approach signal indication would have meant that there was not a train within the next block.

The Board determined that contributing to the accident was the relief engineer's failure to immediately communicate to the engineer that he had miscalled the signal at Englewood and to stop the train when the engineer did not respond to her expressed concern. Also contributing to the accident was an absence of effective crew resource management between the relief engineer and the operating engineer which led to their failure to resolve the miscalled signal prior to the collision.

It is stated in the report that the relief engineer asserted herself after the engineer accelerated the train to 40 mph rather than immediately after she was aware of the miscalled signal at Englewood. Also, she never declared to the engineer that she believed that the Englewood signal was a restricting signal that limited their speed to 15 mph.

Therefore, the Safety Board concluded that the relief engineer failed to communicate effectively and in a timely manner to the engineer that he had miscalled the restricting signal at Englewood interlocking. She also failed to then take action herself to stop the train after the engineer did not slow or stop the train when challenged.

Further contributing to the accident was the absence of a positive train control (PTC) system that would have stopped the Amtrak train when it exceeded restricted speed. The Board concluded that had a PTC system been in place, it would have intervened by stopping the Amtrak train when the engineer failed to comply with the restricted speed.

As a result of its investigation of this accident, the Safety Board made recommendations to the Federal Railroad Administration, Amtrak, the Association of American Railroads, the American Short Line and Regional Railroad Association, the Brotherhood of Locomotive Engineers and Trainmen, the United Transportation Union, and the American Public Transportation Association in the following areas: uniform signal aspects to communicate meanings more effectively, wayside signal indication training and proficiency programs, crew member communication and action in response to operating concerns, and inadequate locomotive cab emergency egress and rescue access. A synopsis of the Board's report, including the probable cause, conclusions, and recommendations, is be available on the NTSB's website; at http://ntsb.gov/events/Boardmeeting.htm The Board's full report will be available on the website in several weeks.

Not surprising here!

ProAmtrak Wrote:
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> Not surprising here!


It doesn't surprise me either, but probably for a different reason. I'm no railroader, but it seems to me there are only three things an approaching train can do at a signal: stop, keep going at it's normal speed, or proceed slowly, ready to stop at the next signal. So the only signals that ought to be needed are red, yellow and green.

What's up with all this "Advance/Approach" (what ever that's supposed to mean), with both a red signal and a green signal displayed simultaineously? If I were trying to invent ways to make a job confusing, I'd be mighty proud to have come up with all the different signal combinations that these poor engineers have to try and memorize, then NEVER get wrong. If the object of the game were to see how many puzzles your train driver can memorize, that would be great. But the object is to avoid collisions, and having a hundred ways to mis-interpret a jumble of colored lights ain't the way to do it. Nobody's going to mis-interpret red, yellow or green.

No, it don't surprise me that the collision describe above occured. What surprises me is that they don't happen a whole lot more often.

I hear ya, just a mistake that is lucky wasn't worse if he was still at full speed!

mstokinger Wrote:
-------------------------------------------------------
> ProAmtrak Wrote:
> --------------------------------------------------
> -----
> > Not surprising here!
>
>
> It doesn't surprise me either, but probably for a
> different reason. I'm no railroader, but it seems
> to me there are only three things an approaching
> train can do at a signal: stop, keep going at it's
> normal speed, or proceed slowly, ready to stop at
> the next signal. So the only signals that ought
> to be needed are red, yellow and green.
>
> What's up with all this "Advance/Approach" (what
> ever that's supposed to mean), with both a red
> signal and a green signal displayed
> simultaineously? If I were trying to invent ways
> to make a job confusing, I'd be mighty proud to
> have come up with all the different signal
> combinations that these poor engineers have to try
> and memorize, then NEVER get wrong. If the object
> of the game were to see how many puzzles your
> train driver can memorize, that would be great.
> But the object is to avoid collisions, and having
> a hundred ways to mis-interpret a jumble of
> colored lights ain't the way to do it. Nobody's
> going to mis-interpret red, yellow or green.
>
> No, it don't surprise me that the collision
> describe above occured. What surprises me is that
> they don't happen a whole lot more often.

In a simplistic world, just red, yellow and green would work, I guess. But to keep things moving more efficiently, we have many combinations of these. Having worked in the West my whole life, I think our signal combinations are much simpler than what the guys in the East have to deal with to accomplish the same objective. I have never, for example, come across a red over yellow aspect that meant restricting, such as in this accident. We would have a flashing red signal or a lunar signal to indicate that. It would be pretty hard to make either one of those out to mean something else. Personally, what engineers have to deal with east of the Mississippi boggles my mind. But, then again, that's why we go through as much training as we do and get paid fairly well for the job we do.

tomk Wrote:
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> "...the Safety Board made recommendations... ...in
> the following areas: uniform signal aspects to
> communicate meanings more effectively..."
>
> That is the main root of this particular problem -
> the lack of uniform/standardized signal aspects
> across the nation.

IIRC that train operates over 5 or 6 segments of different railroads each with their own signal characteristics and rules, no wonder it's so confusing

CB

Yeah but that's always the culprit when they run a signal!

mstokinger Wrote:
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> I'm no railroader,

Oh boy, here we go....


> but it seems
> to me there are only three things an approaching
> train can do at a signal: stop, keep going at it's
> normal speed, or proceed slowly, ready to stop at
> the next signal.

There is a fourth thing that can be done: restricted speed - "proceed prepared to stop within half the range of vision..."


> So the only signals that ought
> to be needed are red, yellow and green.
>
> What's up with all this "Advance/Approach" (what
> ever that's supposed to mean),

Well, I think I understand the point you're trying to make, but it is a bit simplistic and also insulting.

First, I'll concede that the situation in and around Chicago today is tricky (and that may be putting it mildly). I imagine it developed at a time when there wasn't a lot of trackage rights or foreign crews operating over different railroads. But today it has become a lot more complicated for crews, having to memorize multiple signal systems and rule books.

However, the vast majority of crews have properly learned what is required to operate safely in Chicago, as well as many other areas of the country that require the use of multiple rule books.

So it is a bit insulting to imply that railroaders can only be trusted to work with three simple signal colors. And the reality is most signal violations are passing absolute stops (red) that were preceded by an approach (yellow) signal. So simple color lights is not the solution.

The problem is more directly known as "situational awareness", or lack thereof. It is the most important and difficult skill required to operate safely. As much as I dislike the gobblygook of CRM, I have to admit to the truth of "situational awareness" + "technical proficiency" + "Communication" = another safe day at work.

Or more plainly: Pay Attention + know your $h!t + talk = another day's pay!

> As much as I dislike the gobblygook of CRM,

What's CRM?

Highspeed Wrote:

>
> However, the vast majority of crews have properly
> learned what is required to operate safely in
> Chicago, as well as many other areas of the
> country that require the use of multiple rule
> books.
>

> The problem is more directly known as "situational
> awareness", or lack thereof. It is the most
> important and difficult skill required to operate
> safely. As much as I dislike the gobblygook of
> CRM, I have to admit to the truth of "situational
> awareness" + "technical proficiency" +
> "Communication" = another safe day at work.
>
> Or more plainly: Pay Attention + know your $h!t +
> talk = another day's pay!

Well said, HS--having worked in Chicago over this segment, I will second your final sentence--all in favor, "Aye!"

mstokinger Wrote:
-------------------------------------------------------
> ProAmtrak Wrote:
> --------------------------------------------------
> -----
> > Not surprising here!
>
>
> It doesn't surprise me either, but probably for a
> different reason. I'm no railroader, but it seems
> to me there are only three things an approaching
> train can do at a signal: stop, keep going at it's
> normal speed, or proceed slowly, ready to stop at
> the next signal. So the only signals that ought
> to be needed are red, yellow and green.
>
> What's up with all this "Advance/Approach" (what
> ever that's supposed to mean), with both a red
> signal and a green signal displayed
> simultaineously? If I were trying to invent ways
> to make a job confusing, I'd be mighty proud to
> have come up with all the different signal
> combinations that these poor engineers have to try
> and memorize, then NEVER get wrong. If the object
> of the game were to see how many puzzles your
> train driver can memorize, that would be great.
> But the object is to avoid collisions, and having
> a hundred ways to mis-interpret a jumble of
> colored lights ain't the way to do it. Nobody's
> going to mis-interpret red, yellow or green.

The advance/approach signal is just an additional signal telling you what will be happening farther down the track. In the classic sense, the flshing yellow signal says that you should proceed expecting to find the next signal displaying yellow, and that you should reduce your speed. The yellow indicates that the next signal will be red. So, you in effect have two signal blocks to react instead of one.

Because of the longer stopping distances of trains, you need more advance notice to move trains expeditiously.

The same thing goes for places where some other action will be taking place, such as going through a crossover. For example, a red over green signal means that you will be changing tracks, and that you should proceed through the switch at the prescribed speed. The advance indication of this is a red over flashing green.

symph1 Wrote:
-------------------------------------------------------
> > As much as I dislike the gobbledygook of CRM,
>
> What's CRM?

CRM is Crew Resource Management, which was taken from the airline industry's Cockpit Resource Management. See http://en.wikipedia.org/wiki/Crew_Resource_Management

tomk Wrote:
-------------------------------------------------------
> Bruised egos aside,

No bruised ego here, but I have to admit I sometimes don't suffer lightly TO posters who have never worked for a carrier but profess to know better than those who work in it every day.


> I don't believe it is a matter
> of going to three simple color aspects, but rather
> STANDARDIZING signal systems across the nation.

As nice as an idea as that may seem, you gotta know that is even more unlikely than the perfect storm that created the nation-wide mandate for Positive Train Control.

Now, standardizing all signal systems within Chicago might be a good first step, but I'd have to bet against even that at this point in time.

Depending on how PTC is technically implemented, it may make this whole discussion about wayside signals moot.

Highspeed Wrote:
-------------------------------------------------------
> As much as I dislike the gobblygook of
> CRM, I have to admit to the truth of "situational
> awareness" + "technical proficiency" +
> "Communication" = another safe day at work.

I think the biggest pitfall to Crew Resource Management on passenger railroads is the fact that the crew is not in the same physical space (i.e., an airliner cockpit), which means we have to use the radio to implement the "communication" element.

When I first started training on the railroad, I naively asked a question about a grade crossing protect order over the radio. As it turns out, we WERE in the process of "cutting corners" and were not in full compliance with the rule when I asked about it, so I got scolded for mentioning it on the radio. Some people, whether they are correct or not, are under the impression that managers hearing inter-crew communication on the radio will use that information to discipline the crew for technical rule violations.

Whether or not that is true, it's undeniable that the railroad culture is to avoid admitting to potential (I'll call them) "operating irregularities" on the recorded radio channel. This reluctance to speak up about impending situations for fear of discipline is a major hindrance to effective crew communication and Crew Resource Management, IMHO.

While I cannot speak about what happened with this particular wreck, I do not think it is outside the bounds of reason to think a conductor in a similar situation may recognize a problem with the signal called out, but nevertheless avoid correcting the engineer over the radio in order to save face and stay on the "same team" as the engineer.

I mentioned this problem to a manager once and suggested that CRM might be better served if management made a commitment to not charge crews with rule violations based ONLY on radio communications between crew members, but I was told that option was not on the table.

It's been interesting to study the culture of railroading versus what I hear about the culture of the aviation world.

(NOTE: Wikipedia article on CRM: http://en.wikipedia.org/wiki/Crew_resource_management)

Thank you. When I Googled CRM I found articles on Customer Relationship Management.

7
> The same thing goes for places where some other
> action will be taking place, such as going through
> a crossover. For example, a red over green signal
> means that you will be changing tracks, and that
> you should proceed through the switch at the
> prescribed speed. The advance indication of this
> is a red over flashing green.

Here in the west the Advance indication for a Red over Green (Diverging Clear) is either Yellow over yellow (Approach Diverging on the UP) or Yellow over Yellow or flashing Yellow (Approach Medium on the BNSF). A Red over Flashing Green is a Diverging Clear Limited. See how easy the confusion can be WITHOUT a unified signal system!!