1999 — March 15, Amtrak train and Truck Collision, grade crossing, Bourbonnais, IL– 11

—  11  National Highway Traffic Safety Administration. FARS 1975-2010 Fatality Analysis.

—  11  NTSB. Public Hearing, September 13-15, 1999, Chicago, IL.

—  11  NTSB. Railroad Accident Report. Amtrak/Train 59 (NTSB/RAR-02/01). Feb 5, 2002.

—  11  Wikipedia.  “List of Rail Accidents (1950-1999).”

 

Narrative Information

 

NTSB: “Executive Summary: About 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. Total Amtrak equipment damages were estimated at $14 million, and damages to track and associated structures were estimated to be about $295,000.

 

“The National Transportation Safety Board determines that the probable cause of the collision between Amtrak train 59 and a truck tractor-semitrailer combination vehicle at the McKnight Road grade crossing in Bourbonnais, Illinois, was the truck driver’s inappropriate response to the grade crossing warning devices and his judgment, likely impaired by fatigue, that he could cross the tracks before the arrival of the train. Contributing to the accident was Melco Transfer, Inc.’s failure to provide driver oversight sufficient to detect or prevent driver fatigue as a result of excessive driving or on-duty periods….

 

“As a result of this investigation, the Safety Board makes safety recommendations to the U.S. Department of Transportation, the Federal Railroad Administration, all class I and regional railroads, Amtrak, the International Association of Fire Fighters, and the International Association of Fire Chiefs.”  (NTSB/RAR-02/01, Feb 5, 2002, p. v.)

 

“Accident Narrative

 

“Shortly after 8:30 p.m. on March 15, 1999, the driver of the truck involved in this accident picked up his truck tractor semitrailer at Melco Transfer, Inc., (Melco) in Peotone, Illinois. The driver was operating the vehicle under a 60-day probationary license that had been issued in January 1999 after his commercial driver’s license (CDL) was suspended for 90 days because of three traffic citations within a 1-year period.  He drove the truck to the Birmingham Steel plant in Bourbonnais, Illinois. At the plant, the semitrailer was loaded with 6 bundles of 60-foot-long, 3/4-inch-diameter steel reinforcing rods (rebar). When the loading of the flatbed semitrailer was completed, the driver secured the load and drove the truck over weigh scales. The vehicle gross weight was registered at 74,880 pounds. The truck left the plant compound, turned right onto McKnight Road, and traveled eastward about 650 feet to the highway/railroad grade crossing. The grade crossing was equipped with train-activated flashing lights, bells, and automatic gate arms.

 

“Amtrak train 59, the City of New Orleans, originated in Chicago, Illinois, and was bound for New Orleans, Louisiana. The crew reported for duty at 7:15 p.m. Before the train departed, the engineer performed an air brake test. No exceptions were taken. The engineer also stated that he checked the headlight and ditch lights and that they were working properly. The train departed Chicago at 8:03 p.m. The engineer stated that during the trip, the ditch lights oscillated properly at the crossings when he activated the train horn. He also said that the train brakes responded properly each time they were used. At the train’s first scheduled stop, in Homewood, Illinois, no passengers left the train, while an unknown number of passengers boarded. The train departed Homewood at 9:27 p.m.

 

“The accident truckdriver stated that the crossing lights started flashing when he was “right on top of the track.”  He said he did not notice the position of the crossing gates.  The crossing lights had activated on the approach of Amtrak train 59. The truckdriver said he was concerned about braking hard because decelerating too quickly could cause the load on the semitrailer to shift forward and strike the tractor cab.  He said he believed that if he attempted to brake moderately to avoid a load shift, he might bring the truck to a halt on the crossing and in the path of the oncoming train.  He said he was thus momentarily undecided about whether he should attempt to stop or continue across the crossing, but in the end he “just floored it.” He stated that as he traversed the crossing, he looked right and left and saw that the light of the train “wasn’t too far down the tracks then.”  The truckdriver said he believed his vehicle was in sixth gear and traveling about 20 mph at the time of the collision.

 

“Meanwhile, an individual who stated that he was in the Bourbonnais area looking for a used car had mistaken the Birmingham Steel Company parking lot for a used car dealership. Realizing his mistake, he turned around in the parking lot and attempted to reenter McKnight Road.  He said that after waiting for a truck and a passenger car to pass, he turned right onto McKnight Road. He said that the car in front of his was stopped because the lights had begun to flash, and he stopped behind it. He stated that at that time, the truck “was approaching the rail” and that “when the… [gates] were coming down, the trailer was already almost on top of the track and, yes, contact was made with one crossing gate.”  He said the gate struck the right side of the trailer about a third of the way back and that he saw a piece of the gate break off. The witness also stated that the truck moved from the right-hand lane toward the middle of the roadway. He estimated that the truck was traveling about 7 mph at the time.

 

“The train 59 engineer, who was the only person in the locomotive cab at the time, stated that he saw the truck slowly moving over the crossing, and he sounded the train horn to warn the truck-driver. He said that when he realized that the truck would not clear the crossing before the train arrived, he initiated emergency braking.  Traveling at 79 mph, the train did not have sufficient distance to stop and struck the left rear of the semitrailer…The time was about 9:47 p.m.”  (NTSB/RAR-02/01, Feb 5, 2002, 2-3.)

 

“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 had brought a number of hand-held 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, when the steel plant employees were relieved by Bourbonnais Fire Protection District personnel, who continued the extrication efforts….”  (NTSB/RAR-02/01, Feb 5, 2002, 7.)

 

“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, however, 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 about 10:28 p.m., responders used this facility both as a shelter and as a triage site for several persons who were later found to have sustained injuries….”  (NTSB/RAR-02/01, Feb 5, 2002, 8.)

 

“A responding Braidwood Fire Department officer, who was also the emergency response administrator of a petrochemical operation in Elwood, Illinois, said that shortly after he arrived on scene about 10:40 p.m., he recognized that the fire suppression foam at the scene was almost exhausted. He said he also realized that the fire suppression effort had not been effective in extinguishing the locomotive fire. The fire, as he observed it, was “3-dimensional” and petroleum-based, and it remained entrenched within the upper confines of the locomotive carbody wreckage, which made suppression access particularly difficult. He stated that he believed the strategy being used up to that point was having only limited success, because the fire would be extinguished in one location, only to reignite in an adjacent location and flash back to the original location. Further, the fire was directly impinging upon and passing beneath the still-occupied sleeper car 32035.

 

“From this, the Braidwood officer concluded that the application of a large volume of fire suppression foam might be an effective attack strategy and that, therefore, a heavy foam tanker truck from the nearest available facility should be used. The Braidwood officer discussed with the incident commander the possibility of organizing a mutual aid heavy foam tanker truck response to the scene.

 

“The incident commander concurred with this proposed strategy, and the Braidwood officer immediately placed a cellular telephone call asking that a heavy foam tanker truck and personnel from the Stepan Chemical Company near Joliet, Illinois, be dispatched to the accident site. The officer arranged for a similar request to be made to a Mobil Oil refinery. Both facilities are about 35 miles away from the accident scene, and the officer anticipated that the trucks might require about 45 minutes to arrive….

 

“About 11:30 p.m., a heavy foam tanker truck from Stepan Chemical Company arrived and was directed to the west side staging area. About 11:45 p.m., the foam tanker truck reached the west side staging area and set up near the wreckage pileup. The Braidwood Fire Department officer who organized the Stepan response directed that water supply connections be made to one of the pumper trucks stationed at that location and that fire suppression by hand-line commence immediately. Fire suppression water/foam solution was applied to the main body of the fire in the proximity of the locomotive and the sleeper car until the fire was extinguished; the fire was out within a few minutes.  Water/foam solution application continued periodically thereafter, because firefighters were concerned that hot metal in the wreckage might re-ignite the fire….”  (NTSB/RAR-02/01, Feb 5, 2002, 8-9.)

 

“Injuries

 

“Eleven train passengers, all of whom were located in sleeper car 32035, 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. Rescuers reported that they were unable to immediately extricate some of the individuals they believed to be entrapped within the wreckage; the Kankakee County coroner tentatively attributed injuries of 5 of the 11 fatally injured occupants to the effects of the fire. The coroner was unable to determine whether any of these 5 might have succumbed to their traumatic

injuries had they not been exposed to the fire….”  (NTSB/RAR-02/01, Feb 5, 2002, 10-11.)

 

“Truckdriver

 

“The accident-involved truckdriver, aged 58, had been driving commercial vehicles since about 1960. He had been traversing this crossing 5 days per week for about 7 years at the time of the accident. The truckdriver had worked for Melco Transfer, Inc., as an owner-operator since 1990….”  (NTSB/RAR-02/01, Feb 5, 2002, 11.)

 

“The accident driver’s CDL was suspended for failure to pay the fine associated with…[a] June 18, 1998, speeding citation, but it was reinstated on September 29, 1998.  Illinois has a uniform citation form that indicates whether a violator holds a CDL and whether the violator was operating a commercial vehicle. This information is entered in the driver’s motor vehicle record. Illinois also enters violation information from other States. Because of this information interchange, the State of Illinois noted that the truckdriver had received three citations within 1 year in Indiana. On this basis, in the fall of 1998, the State of Illinois informed the truckdriver that his CDL would be suspended after 90 days, effective January 25, 1999. When the truckdriver was notified that his CDL was subject to suspension, he enrolled in the National Safety Council’s driver improvement program. Following the truckdriver’s successful completion of this course in January 1999, the State of Illinois issued the accident driver a probationary license for a period of 60 days beginning on January 25, 1999, and ending on March 25, 1999.[1]

 

“In May 1999, following the accident, the truckdriver’s license was again suspended for 60 days, because he was convicted of two serious traffic violations during a 3-year period (two of the four speeding violations). The driver’s CDL was reinstated on August 1, 1999. In November 1999, the same truckdriver was cited for a moving violation and received court supervision. He was not convicted, and his license was not suspended.

 

“The citations instigating the initial license suspension were related to speeding, and not to grade crossings. However, in 1999, the U.S. DOT’s Federal Highway Administration added a regulation creating a new category of offenses for which a CDL holder may be disqualified from operating a commercial motor vehicle. The rule specifically covers convictions for six types of offenses, including failure to obey traffic control devices at grade crossings. Under the rule, conviction for one of six specific violations at a grade crossing results in an automatic CDL suspension of not less than 60 days. Upon the second conviction within a 3-year period (for a separate incident), the driver must be disqualified for 120 days. Following a third and subsequent violation within a 3-year period, a driver must be disqualified for not less than 1 year. The accident truckdriver was not charged with a grade crossing violation as a result of this accident.  Following the accident, however, the Federal Office of Motor Carrier Safety conducted a compliance review of Melco Transfer, Inc., that resulted in fines for both the motor carrier and for the accident truckdriver. The Federal Motor Carrier Safety Administration has elected not to pursue the case further, but instead has turned the case over to the DOT’s Office of the Inspector General, who is conducting a criminal investigation into circumstances surrounding this accident. In October 2001, the accident-involved truckdriver was indicted by a Kankakee County grand jury on two counts. One count of the indictment alleges that he falsified his logbook. The second alleges that he violated the hours of service regulations. Both are felony charges.”  (NTSB/RAR-02/01, Feb 5, 2002, 12)

 

“Shortly after the accident, Safety Board investigators compiled the activities of the truckdriver for the 72-hour period before the accident using the truckdriver’s statements, his logbook, and materials from the Illinois State Police investigation. A preliminary compilation indicated that the truckdriver had been driving for about 10 hours and had been on duty for another 2 hours in the 24-hour period before the accident. However, during the accident investigation, investigators discovered a fuel receipt that contradicted the driver’s account of his whereabouts on the day before the accident. When confronted with the evidence by investigators, the truckdriver submitted a revised statement….”  (NTSB/RAR-02/01, Feb 5, 2002, 13)

 

“Train Information

 

“….Directly behind the two locomotives followed a baggage car, a crew dormitory (transition sleeper) car, and sleeping car 32035. The accident’s 11 fatalities were sustained in car 32035. As a result of the derailment and subsequent pileup, the sleeping car came to rest bent and wrapped around the aft end of the second locomotive unit. The carbody, bent an estimated 56 degrees, sustained substantial crush damage and a large breach area where it made contact with the second locomotive. In addition, the aft end of the car experienced a longitudinal twist of about 50 degrees. The left front sidewall was displaced and crushed inward about 6 feet through impact with the forward end of coach 34089, a following car.  A length of running rail also longitudinally penetrated the lower level of the carbody, piercing several of the sleeping compartments. In addition to the crush and deformation damage caused by the derailment, a fire, ignited in fuel that spilled from the second locomotive and that migrated underneath the sleeping car, impinged on this car, which then itself ignited. An inspection of the interior of the sleeping car revealed that most of the partitions, fittings, and fixtures in the forward two-thirds of the car were catastrophically crushed and consumed by fire; the material in the aft one-third showed evidence of smoke damage.”  (NTSB/RAR-02/01, Feb 5, 2002, 16)

 

“Motor Carrier Information

 

“The truckdriver was an owner-operator and owned the accident truck tractor, while Melco owned the trailer. The accident load was being transported under Melco authority.  Melco is an authorized for-hire interstate carrier that was established in 1986. At the time of the accident, the carrier operated 41 trucks and owned or leased 55 trailers, primarily hauling steel throughout the Midwest. According to the company, about 95 percent of Melco drivers were owner-operators. Melco vehicles accumulated a total of 2,926,355 miles in the 12 months ending February 28, 1999….

 

“After the accident, on March 17, 1999, the Federal OMC conducted a compliance review of Melco….Title 49 CFR Part 395 requires motor carriers to maintain drivers’ log records for a period of 6 months. The OMC compliance review determined that the company had not kept accurate records of duty status for about one-half of the drivers reviewed…this category was rated “Unsatisfactory.” The OMC review of the carrier’s maintenance records revealed that the carrier had failed to maintain records of repairs and maintenance. The OMC noted that the carrier also lacked a means to indicate the nature and due dates of these repairs and maintenance.

 

“Melco Transfer, Inc., was given a “Conditional” rating and fined $4,050 as a result of the review. The driver was also fined $2,000 for falsifying his records of duty status.  The OMC conducted a return review in August 1999; this review indicated that Melco had corrected the majority of the violations for which it had been cited. As a result, the motor carrier’s rating was upgraded from “Conditional” to “Satisfactory”….

 

“ On the day of the accident, the truckdriver delivered a load of steel from Birmingham Steel in Bourbonnais, Illinois, to Dayton, Ohio. The driver then transported a “back-haul” of lift trucks from Princeton Products in Canal Winchester, Ohio, to Country Supply in Peotone, Illinois. The driver had begun his third trip of the day, with a load of steel, when the accident occurred.

 

“During the investigation, Melco officials indicated that the company had contracted for the two loads of steel and had assigned those loads to the truckdriver; however, these officials stated that they were unaware of the back-haul load. Further investigation revealed that Country Supply–the recipient of the back-haul of lift trucks–and Melco had a routine business relationship and that Melco owned Country Supply until 1997. The two businesses were located in the same industrial complex. Driver and billing records showed that Melco drivers, including the accident driver, frequently transported loads between Princeton Products and Country Supply, and Country Supply was billed by Melco for transportation services associated with these deliveries. According to the records, these shipments were always arranged by Country Supply. According to Country Supply representatives, the company never received a bill for the back-haul load on the day of the accident….”    (NTSB/RAR-02/01, Feb 5, 2002, 17-18)

 

“Roadway and Grade Crossing Information

 

“….Traffic Control Devices.  The Manual on Uniform Traffic Control Devices (MUTCD), published by the Federal Highway Administration and adopted as law by the States, requires special pavement markings in each approach lane of all paved approaches to grade crossings where automated signals are present.  The required markings are an “X,” the letters “RR,” a no-passing-zone marking, and certain transverse lines. With the exception of no-passing-zone markings, none of these markings were present on the McKnight Road approach to the accident crossing. The no passing zone on the eastbound approach to the tracks extended 315 feet but was in poor condition.  According to Village of Bourbonnais officials, the practice of the village was not to stripe roads of this type and function, and the no-passing-zone markings had not been repainted since the village acquired ownership of the road….

 

“A driver or pedestrian approaching the grade crossing would have been warned of an approaching train by bells, flashing red lights, and crossing gate arms. To the driver involved in this accident, the west gate was on the approach side of the crossing, and the east gate was on the departure side. The crossing gate masts were 12 feet from the nearest rail.

 

“According to the State of Illinois, a motorist must stop at a grade crossing if the crossing is equipped with a “Stop” sign, if a train is approaching and/or gives a warning, if a flagman indicates a stop is required, or if a train-activated warning device is activated.  When approaching a crossing equipped with flashing lights, the driver is required to “always stop until it is safe to proceed.”…If the flashing lights are accompanied by an automatic gate arm, then the motorist is required to stop and remain stopped until the gate is raised again….”   (NTSB/RAR-02/01, Feb 5, 2002, 22-23)

 

“Current Status of McKnight Road Crossing

 

“ The Illinois Commerce Commission, in conjunction with the Village of Bourbonnais, has considered making improvements to the grade crossings at McKnight Road and at St. George Road, immediately to the north of McKnight Road. In October 2000, temporary highway signals were put in place at St. George Road and were interconnected with the railroad grade crossing signaling system. In addition, pre-signals, designed to stop highway traffic before reaching the crossing, were installed for eastbound traffic on St. George Road. Further improvements to St. George Road are planned, including relocating the crossing 500 feet east of the existing crossing to eliminate the need for traffic signal interconnection, widening the crossing, upgrading the crossing warning devices, and installing a barrier median at the crossing. Before agreeing to these changes, the Illinois Commerce Commission had an engineering diagnostic team evaluate the crossing. Costs for the relocation and reconfiguration of the St George Road crossing will be borne by the Illinois Department of Transportation. For the widening of the crossing and the upgrade of crossing warning devices, about $215,700 will be paid from the grade crossing protection fund, monies provided to the States by the Federal Highway Administration. Any additional costs, including the cost of future maintenance, will fall to the CNIC railroad….”  (NTSB/RAR-02/01, Feb 5, 2002, 44)

 

“Analysis

 

“….The truckdriver, therefore, maintained that the amount of time between activation of the signal lights and the arrival of the train was insufficient to permit him to clear the crossing. Staff reviewed the driver’s testimony, and all of the postaccident tests and analyses, to determine if the preponderance of evidence supports the driver’s contention, or if an alternative scenario could explain the actual events leading up to the accident.  Specifically, staff examined some of the key facts reported by the truckdriver, including:  the truck’s speed before the collision; the truck’s distance from the tracks when the red crossing lights first came on; the operation of the crossing lights and crossing gate; and the time that the driver first observed the crossing lights….

 

“The Safety Board concludes…that the grade crossing signal lights began flashing at least 26 seconds before the train’s arrival at the McKnight Road grade crossing….

 

“ The driver stated that he did not notice the movement of the gates at the crossing (whether they were in the process of moving, or whether they were in an upright or down position) as he approached the tracks. According to the truckdriver, when he first saw the crossing lights flashing, he quickly decided to accelerate, and he focused his attention primarily on moving the truck straight ahead and across the tracks.

 

“Computer simulations conducted by the Safety Board as part of this accident investigation provided evidence that disputes the truckdriver’s account…two different analysts used different software programs to simulate the accident, generating hundreds of simulations. The simulations were not only used to estimate the truck speed, they were also used in an attempt to determine whether the physical evidence, particularly the tire marks, were more likely created by a truck driving more or less straight through the crossing with a delayed gate or by a truck driving around lowered gates. The analyses indicated that in order for the truck to have made the tire marks found at the scene, it must have been at an angle such that, at the time of impact, the right front tire of the tractor was near its final position and the left front axle of the trailer was to the left of the highway centerline….the simulations indicate that the data are best matched when the truck is driven as though to avoid lowered or lowering crossing gate arms….

 

“Fatigue

 

“In a revised statement, the truckdriver changed his initial account of the amount of sleep he had received on the day of the accident, reporting that he had slept for a total of 4 hours, 45 minutes, most in the sleeper berth but with a small amount of sleep at home immediately before the accident trip. Therefore, combining the 2 hours, 30 minutes, of rest the driver reported he received on Sunday night before reporting to work with the 4 hours, 45 minutes, he reported receiving on Monday would suggest that he accumulated 7 hours, 15 minutes, of fragmented sleep before the accident. A close examination of the various trip segments on Monday, however, suggests he had even less sleep. Based on Safety Board calculations of trip times and lengths, it is unlikely that the driver could have completed the majority of his trip in the amount of time he reported. The calculations indicate the trip would have taken about 1 hour and 45 minutes longer than the driver reported, thus allowing that much less time to sleep.

 

“In addition, according to the accounts of the shippers and receivers of his trip loads, it appears that the truckdriver participated in the loading and offloading of his cargo, thus further reducing the time available for sleep. The amount of time needed to complete loading and offloading activities is not known, which prevents an exact determination of the amount of time the driver had for sleep on Monday. But based on all available evidence, the truckdriver accrued only 3 to 5 hours of fragmented sleep in the 38 hours (Sunday and Monday) before the accident.

 

“Fragmented sleep, such as that experienced by the driver in this accident, has been associated with driver fatigue and a resulting decrease in performance. Research has shown that sleep accumulated in short time blocks is less refreshing than sleep accumulated in one long time period…Safety Board research indicates that the duration of the most recent sleep period, the amount of sleep during the previous 24 hours, and split or fragmented sleep patterns are among the most critical factors leading to fatigue-related accidents…As indicated above, the truckdriver’s cumulative sleep total for the 24 hours before the accident was about 3 to 5 hours, well below the average of 6.9 hours slept by truckdrivers involved in fatigue-related accidents examined by the Safety Board.  Truckdrivers involved in non-fatigue-related accidents averaged 9.3 hours of sleep within the previous 24 hours. The Bourbonnais accident-involved truckdriver’s most recent sleep period lasted about 1 to 2 hours. In the Safety Board’s study, the fatigue-related-accident truckdrivers had slept an average of 5.5 hours, and the non-fatigue-related-accident truckdrivers had slept an average of 8.0 hours in their most recent sleep periods before their accidents.

 

“Research…has demonstrated how sleep loss is associated with decrements in decision-making, vigilance, reaction time, memory, psychomotor coordination, and information processing (for example, fixation on certain material to the neglect of other information).  An operator may react slowly to information, may incorrectly process the importance of the information, may find decision-making difficult, or may make poor decisions. This performance degradation can be a direct result of sleep loss and the associated sleepiness and can play an insidious role in the occurrence of an operational incident or accident.

 

“It is likely that the small amount of sleep the truckdriver had obtained resulted in decrements in one or more of the following: his decision-making, vigilance, reaction time, memory, psychomotor coordination, or information processing. These decrements may have caused the truckdriver to miss the onset of the grade crossing signal indication and to preclude his braking in time to avoid stopping on the tracks. Such an event is consistent with the driver’s contention that the grade crossing warning lights did not activate until he was very close to the crossing and may have lead to the truckdriver’s risky actions well after the warning system had actually been activated.

 

“Despite the fact that the truckdriver was suffering from fatigue at the time of the accident, investigators could not determine the extent to which fatigue accounted for his performance. Investigators could, however, determine that at least some of the truckdriver’s statements lacked credibility and that the accident did not happen exactly as the truckdriver described it….

 

“The truckdriver said he did not notice the position of the crossing gates. But eyewitnesses stated that the truck crossed the centerline of the roadway as it attempted to navigate the crossing. Also, computer simulations indicated that the truck, when struck, was moving from the left lane back into the right lane. This movement suggests either that one or both gates were down when the truck began to move over the crossing or that the truckdriver was anticipating the lowering of the gates and was maneuvering to avoid them when the collision occurred.

 

“Based on all available evidence, the most likely scenario is that the signal lights began flashing as the truck was some distance from the crossing. The possibility exists that the truckdriver may not have noticed the flashing signal lights when they first activated. But the fact that those lights were seen by a crane operator who was as much as 600 yards away from, and at an angle to, the crossing makes it unlikely that they would have not been seen by the truckdriver only a few hundred feet away unless the driver was either sleep-deprived or distracted in some way. But according to witnesses, the truckdriver reduced throttle, which applied the jake brake, and he may have applied the brakes and further slowed, which suggests that he did, indeed, see the lights. At some point, as he continued to approach the crossing, the truckdriver made a judgment that he could clear the crossing before the train arrived. Perhaps he was misled by the normal delay in the lowering of the gates, or he may have assumed that the train was a slowmoving freight train rather than a passenger train…Whatever the basis of the truckdriver’s judgment and whether or not it was affected by fatigue, by the time the truck reached the crossing, most of the warning time had elapsed, and the arrival of the train was imminent.  Considering the speed he was traveling and the length of his truck, the truckdriver had no chance to avoid a collision once he committed to attempting to cross in front of the train.

 

“The Safety Board therefore concludes that the truckdriver had ample time to safely stop his truck and avoid an accident, but likely as a result of fatigue, he failed to respond appropriately to the signals and instead decided to attempt to cross ahead of the train.

 

“Motor Carrier Performance

 

“On the day of the accident, the truckdriver exceeded the work hours specified in the Federal Motor Carrier hours-of-service rules…Since the truckdriver’s last consecutive 8-hour off-duty period, he had been driving for more than 13 hours (10 hours are allowed) and had been on-duty for almost 20 hours (15 hours are allowed). Furthermore, at the time of the accident, the truckdriver was beginning another trip that would have put his duty/rest cycle even more out of balance and would have aggravated his already fatigued condition.

 

“Originally, the Safety Board was led to believe that on the day of the accident, the truckdriver had transported the first load of steel and had returned home empty. According to this scenario, he was off duty at home and returned to work shortly before the accident to pick up his second load of steel of the day. Had this scenario been accurate, the driver would have been just within the hours-of-service rules, having driven for about 10 hours, then having about 8 hours of off-duty time before driving again. However, during the investigation, a back-haul was discovered. This back-haul load resulted in the driver’s exceeding the hours-of-service limitation and led to his fatigued condition. Melco indicated that although it had scheduled the two loads of steel, the company was unaware of the back-haul. However, investigators found that the company (Country Supply) that arranged the load was closely associated with Melco, and loads similar to the accident back-haul load were frequently transported by Melco drivers, including the accident driver. Furthermore, Melco routinely billed Country Supply for the transportation services associated with those loads. Although Melco denied knowledge of the back-haul load, it appears that Melco probably knew about the load and may even have assigned it to the driver….

 

“…the Safety Board concludes that Melco failed to provide driver oversight sufficient to detect or prevent driver fatigue as a result of excessive driving or on-duty periods….”  (NTSB/RAR-02/01, Feb 5, 2002, 46-57)

 

“Emergency Response

 

“The effectiveness of emergency response is affected by the preparations made by local jurisdiction responders and by the railroads involved. Because Amtrak is not able to provide on-site training to every emergency response agency within the territories through which it operates, these agencies often face the prospect of responding to a passenger train emergency without any real knowledge about the particular hazards passenger trains may present. In other words, 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 on-site instruction or training in responding to such emergencies.

 

“The 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, and within a few minutes of this equipment beginning to apply foam, the fire was extinguished. Before the arrival of the Braidwood officer, on the other hand, 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. The Safety Board concludes that because of insufficient training in responding to railroad emergencies or inadequate/ inappropriate resources, or both, the Bourbonnais Fire Protection District was not prepared to respond effectively to a train accident involving a significant diesel fuel fire.

 

“Even though modern locomotives, such as the ones involved in this accident, are designed with improved protection for fuel tanks, the possibility of a fuel leak and fire present anywhere a major railroad accident occurs. The Safety Board believes that Amtrak, in fulfilling its Federal mandate to help prepare emergency responders to respond to an accident involving Amtrak equipment, should emphasize to those responders the possibility that such an accident could result in large quantities of burning diesel fuel and urge them to be prepared to respond to this specific hazard. The Safety Board further believes that the International Association of Fire Fighters and the International Association of Fire Chiefs should inform their memberships of the circumstances surrounding this accident and of the need for responders to prepare for train accidents that may result in significant diesel fuel fires.”  (NTSB/RAR-02/01, 5Feb2002, 57-58)

 

“Train Evacuation Effort

 

“The Amtrak National Operations Center told emergency responders that the train could be carrying as many as 400 passengers. When Amtrak management arrived on scene, this number was lowered to 196. Several days after the accident, Amtrak identified the number of “confirmed” passengers to be 198. However, it was several more days before a complete list of passenger names was developed by Amtrak, 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 could be determined.

 

“The difficulty in determining the number of passengers involved may have put emergency responders at unnecessary risk. As the fire progressed, entry into some of the overturned cars became more hazardous, but rescuers repeatedly risked their own safety, returning to the cars in order to help the trapped occupants. They stopped only when the fire made it impossible for them to help any further. In some cases, rescue workers were able to identify locations where people were trapped. In other cases, however, because of the confusion over the number of passengers actually aboard the train, they may have been searching for unaccounted-for passengers who did not really exist.

 

“Amtrak’s passenger train emergency preparedness plan contained no elements addressing the need to provide an accurate count of train occupants to local emergency responders in the event of a passenger train emergency. Nor do the Federal regulations require such a section. As the confusion following this accident shows, however, the lack of a reasonably accurate count can lead to rescue personnel risking their lives needlessly.  In September 1994, the Safety Board published a report on its investigation into an Amtrak accident in Mobile, Alabama…

 

“In this report, the Safety Board highlighted the value of providing emergency responders with an accurate count of train occupants, recommending that Amtrak:

 

R-94-7

 

Develop and implement procedures to provide adequate passenger and crew lists to local authorities with minimum delay in emergencies.

 

“Amtrak responded with a plan to develop a satellite and long-distance messaging system between long-distance trains and corporate offices. One benefit of this proposed new communications system would be improved passenger manifests. Following a 1997 Amtrak accident in Kingman, Arizona…Amtrak indicated to the Safety Board that such manifests were unlikely to become possible on unreserved trains, because of the many stops these trains make. The railroad did state, however, that computer systems exist that would enable them to provide such a list for reserved trains. As a result of these communications, the Safety Board closed the 1994 recommendation and issued a new recommendation urging Amtrak to:

 

R-98-58

 

Expedite the development and implementation of a passenger and crew accountability system on reserved trains.

 

“Based on Amtrak responses in 2000, in which the railroad stated that it had implemented a system to account for all train occupants, the Safety Board classified this recommendation “Closed–Acceptable Action” in December 2000.”  (NTSB/RAR-02/01, 5 Feb 2002, 58-60)

 

“Roadway Geometry/Highway Condition

 

“….Railroad pavement markings, consisting of an X, the letters “RR,” certain transverse lines, and “no passing” double solid yellow centerlines, were required by the MUTCD; none of these were in place. One intent of pavement markings is to inform the motorist that he is approaching a railroad crossing….

 

“As a result of its investigation of a March 14, 1982, accident in Mineola, New York…in which an impaired driver crossed the centerline to go around lowered gates and was struck by a Long Island Railroad commuter train, the Safety Board recommended that the Federal Highway Administration (FHWA):

 

H-82-052

 

Review the effectiveness of guidelines in the Manual on Uniform Traffic Control Devices (MUTCD) on the use of traffic divisional islands to deter motorists from driving around lowered railroad crossing gates…

 

“The FHWA responded that the subject would be covered in the Railroad-Highway Grade Crossing Handbook in 1984 (actually published in 1986). The handbook (a new edition is being prepared) states that “traffic divisional islands may be used at crossings on multi-lane roadways to prevent motorists from driving around a lowered gate.” The recommendation was classified “Closed–Acceptable Action” in 1987.

 

“The Swift Rail Development Act, passed in 1991, required that regulations be established to require that a train’s horn be sounded on the approach to public highway/rail grade crossings except when supplemental safety measures fully compensate for the absence of audible warning, when there is no significant risk to persons, or when it is not practical (as is the case during certain backing movements). In response to the Swift Act, on January 13, 2000, the FRA published a notice of proposed rulemaking (NPRM) entitled “Use of Locomotive Horns at Highway-Rail Grade Crossings.” In this NPRM, the FRA indicates that the supplemental safety measures that would be considered adequate would include (1) four-quadrant gates, (2) medians or channelization devices at gated crossings, (3) paired one-way streets, (4) temporary crossing closure (for example, crossing closed at night), or (5) the use of photo-enforcement technology. The NPRM also indicated that in addition to the supplemental safety devices, all crossings within a quiet zone had to be equipped with train-activated lights and gates. The period for comments on the NPRM closed May 26, 2000; the FRA has received more than 2,300 comments. To give the public an opportunity to provide oral comments, the FRA also conducted a series of public hearings on the matter in California, the District of Columbia, Florida, Illinois, Indiana, Massachusetts, Ohio, and Oregon. According to the FRA’s Office of Safety, the rule is expected to be completed by spring 2002.

 

“Given the reasons detailed above, the Safety Board is pleased to note that the Village of Bourbonnais has installed temporary median barriers in McKnight Road in the vicinity of the grade crossing until such time as the crossing can be closed.”  (NTSB/RAR-02/01, 5Feb2002, 60-61)

 

“Reducing Traffic Violations at Grade Crossings

 

“The Safety Board is pleased to note the steps that have been taken in Illinois and nationwide to improve grade crossing safety through better enforcement of traffic laws at grade crossings. For example, not only do new Federal regulations promulgated in 1999 prevent States from granting a provisional, probationary, or other temporary license to a CDL holder whose CDL has been suspended, the new regulations require CDL suspension for a driver convicted of a grade crossing violation. Further, current Illinois State law provides that motorists convicted of grade crossing violations may be fined up to $500. In the case of CDL holders, both the fine and the potential loss of income (by CDL suspension) should provide an incentive for CDL holders to exercise greater caution at grade crossings.

 

“But while greater penalties for grade crossing violations are welcomed, their deterrent effect can be undermined if motorists perceive that they face little threat of detection or apprehension. To address this problem, some States, localities, and other entities have developed innovative ways of approaching grade crossing enforcement. For example, Operation Lifesaver…organizations in several States have conducted programs to place law officers on trains and at stationary locations along the trains’ routes. The officers at the stationary locations stop and ticket those motorists identified by on-board officers as having violated traffic control devices at crossings. While programs such as this can increase law enforcement awareness of grade crossing violations, in some States they are conducted only sporadically. As noted above, motorists who encounter what is, at best, limited and intermittent enforcement of traffic laws at grade crossings may conclude that it is possible to violate those traffic laws with some impunity.

 

“To increase the likelihood that grade crossing violations will not go undetected, some States, municipalities, and railroads have turned to the use of photo enforcement at grade crossings. In use throughout the world for more than 40 years…photo enforcement technology such as that used for identifying and citing those who run red lights has recently been adapted for use at grade crossings. In 1995, for example, the Los Angeles Metropolitan Transportation Authority (MTA) began a photo enforcement program that has been credited with reducing by almost 50 percent the number of grade crossing violations detected at 17 gated crossings along the Metro Blue Line route…Encouraged by the program’s success, the MTA is planning to expand its use of photo enforcement by installing six more crossing video systems during the first half of 2002.

 

“A grade crossing photo enforcement pilot program has also recently been established in Illinois. The Illinois General Assembly in 1996 required the Illinois Commerce Commission to conduct a study of the effectiveness of photo enforcement at grade crossings. According to the commission, it selected three grade crossings in DuPage County, Illinois, for the test. Because of difficulties in establishing contracts, as well as construction problems, the three sites were completed at different times. Fully functional in January 2000, photo enforcement at the grade crossing in the city of Wood Dale achieved a 47-percent decrease in the number of violations between January and September 2000. This crossing, which had formerly experienced three to four collisions per year had only one collision in the pilot program’s first 13 months of operation. Photo enforcement at the grade crossing in the city of Naperville was functional in July 2000, and the crossing has seen a 51-percent reduction in the number of violations.

 

“According to the FRA, the State of North Carolina has established, with Federal assistance, a program to eliminate grade crossing hazards as part of an attempt to develop a high-speed rail corridor within its borders…Known as the Sealed Corridor Initiative, the program calls for the improvement or closure of every crossing along the proposed corridor. The plans include installation of four-quadrant gates, longer gate arms, and median barriers as well as video enforcement of grade crossing traffic laws. The testing of the video enforcement project has recently begun.

 

“In the Safety Board’s 1998 grade crossing safety study…the Safety Board noted the sporadic nature of traffic law enforcement at passive crossings (those without train-activated warning devices). In order to promote better law enforcement at passive crossings, the Safety Board issued the following safety recommendation to the Secretary of Transportation:

 

H-98-29

 

Provide Federal highway safety incentive grants to States to advance innovative pilot programs designed to increase enforcement of passive grade crossing traffic laws.

 

“After the DOT indicated that it had made inquiries to State and local law enforcement for suggestions regarding enforcement programs, the Safety Board classified Safety Recommendation H-98-29 “Open–Acceptable Response.”

 

“Whereas this recommendation was directed to enforcement at passive grade crossings, this accident, as well as subsequent violations recorded at the McKnight Road and St. George Road grade crossings, indicates that grade crossings equipped with train-activated warning devices could also benefit from innovative enforcement programs such as the photo enforcement programs employed in several locations. The Safety Board therefore believes that the DOT should provide Federal highway safety incentive grants to States to advance innovative pilot programs designed to increase enforcement of grade crossing traffic laws at both active and passive crossings. This recommendation replaces Safety Recommendation H-98-29, which has been reclassified “Closed–Superseded.”  (NTSB/RAR-02/01, Feb 5, 2002, 61-63)

 

“Conclusions

 

“Findings….

 

“5. The truckdriver had ample time to safely stop his truck and avoid an accident, but likely as a result of fatigue, he failed to respond appropriately to the signals and instead decided to attempt to cross ahead of the train.

 

“6. Melco Transfer, Inc., failed to provide driver oversight sufficient to detect or prevent driver fatigue as a result of excessive driving or on-duty periods….

 

“8. Because of insufficient training in responding to railroad emergencies or inadequate/ inappropriate resources, or both, the Bourbonnais Fire Protection District was not prepared to respond effectively to a passenger train accident involving a significant diesel fuel fire.”  (NTSB/RAR-02/01, 2-5-2002, 64)

 

“New Recommendations

 

“To the U.S. Department of Transportation:

 

Provide Federal highway safety incentive grants to States to advance innovative pilot programs designed to increase enforcement of grade crossing traffic laws at both active and passive crossings. (H-02-1)

 

“To the Federal Railroad Administration:

 

For all railroads that install new or upgraded grade crossing warning systems that include crossing gates and that are equipped with event recorders, require that the information captured by those event recorders include the position of the deployed gates. (R-02-1)

 

“To All Class I Railroads:

“To All Regional Railroads:

 

For all your new and upgraded grade crossing warning systems that include crossing gates and that are equipped with event recorders, ensure that the information captured by those event recorders includes the position of the deployed gates. (R-02-2)

 

“To the National Railroad Passenger Corporation:

 

In fulfilling your Federal mandate to help prepare emergency responders to respond to an accident involving Amtrak equipment, emphasize to those responders the possibility that such an accident could result in large quantities of burning diesel fuel and urge them to be prepared to respond to this specific hazard. (R-02-3)

 

“To the International Association of Fire Fighters:

“To the International Association of Fire Chiefs:

 

Inform your membership of the circumstances surrounding the emergency response to the March 15, 1999, grade crossing accident in Bourbonnais, Illinois, and of the need for responders to prepare for train accidents that may result in significant diesel fuel fires. (R-02-4)

 

(NTSB/RAR-02/01, 2-5-2002, 65-66)

 

Wikipedia: “March 15, 1999 – Bourbonnais train accident, Bourbonnais, Illinois, United States: The southbound Amtrak City of New Orleans, traveling at approximately 80 miles per hour (130 km/h), slams into a semi-trailer truck loaded with steel concrete reinforcing bar (rebar) at a grade crossing and derails. An ensuing fire sets one Superliner sleeper car ablaze. Eleven were killed and over 100 were injured. It was subsequently determined that the truck driver had ignored the grade crossing signals and drove around the lowered gates.” (Wikipedia. “List of Rail Accidents (1950-1999).”)

Sources

 

National Highway Traffic Safety Administration. Partial Data Dump of Crashes Involving 10 or More Fatalities, by Year, Fatality Analysis Reporting System (FARS) 1975-2009 Final and 2010 ARF. Washington, DC: NHTSA, pdf file provided to Wayne Blanchard, 1-26-2012.

 

National Transportation Safety Board. “Board Meeting: Collision of Amtrak Train 59 with a Loaded Truck Tractor-Semitrailer Combination at a Highway/Rail Grade Crossing in Bourbonnais, Illinois, March 15, 1999.” Accessed 12-13-2015 at: http://www.ntsb.gov/news/events/Pages/Collision_of_Amtrak_Train_59_with_a_Loaded_Truck_Tractor-Semitrailer_Combination_at_a_HighwayRail_Grade_Crossing_in_Bourbo.aspx

 

National Transportation Safety Board. Railroad Accident Report. 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/RAR-02/01). Wash., DC:  February 5, 2002, 77 pages. Accessed 12-13-2015 at: http://www.ntsb.gov/investigations/AccidentReports/Reports/RAR0201.pdf

 

Wikipedia. “List of Rail Accidents (1950-1999).” http://en.wikipedia.org/wiki/List_of_1950-1999_rail_accidents

 

 

[1] “Under the Motor Carrier Safety Improvement Act of 1999, effective January 23, 2000, States are now prohibited from awarding a probationary license to a CDL holder while he or she has been disqualified from operating a commercial motor vehicle.”  (Footnote 10 in NTSB/RAR-02/01, Feb 5, 2002, 12.)