National
Transportation Safety Board
Highway Accident Report
Public Meeting
of Oct. 29, 1996
Abstract of Final Report
School Bus Commuter Train Accident
Fox River Grove, Illinois
October 25, 1995
Executive
Summary
On
October 25, 1995, at 7:10 a.m., the Northeast Illinois Regional Commuter
Railroad Corporation (Metropolitan Rail) express commuter train 624 struck
the rear left side of a stopped Transportation Joint Agreement School
District 47/155 school bus at a railroad-highway grade crossing in Fox
River Grove, Illinois. After the school bus crossed the railroad tracks
and stopped for a red traffic signal, its rear extended about 3 feet into
the path of the train. Of the 35 school bus passengers, 7 were killed,
24 suffered serious to minor injuries, and 4 received no injuries. The
bus driver received minor injuries. The 120 passengers and 3 crewmembers
aboard the commuter train were uninjured.
The major safety issues discussed in this report are
appropriateness of the bus driver's performance; adequacy of the school
district bus routing and bus driver monitoring and evaluating procedures;
road design; railroad/highway signal interaction; coordination and communication
between the Illinois Department of Transportation and the Union Pacific
Railroad Company and their oversight of the signal system integration;
and injury and survival factors in the school bus.
As a result of its investigation of this accident, the
Safety Board makes recommendations to the U.S. Secretary of Transportation,
the Federal Highway Administration, the Federal Railroad Administration,
the National Highway Traffic Safety Administration, the State of Illinois,
the Transportation Joint Agreement School District 47/155, the National
Association of State Directors of Pupil Transportation Services, the American
Association of State Highway and Transportation Officials, the National
Association of County Engineers, the American Public Works Association,
the Association of American Railroads, the American Short Line Railroad
Association, the American Public Transit Association, and Operation Lifesaver,
Inc. The Safety Board also issued urgent action recommendations following
this accident to the Federal Highway Administration, the Federal Railroad
Administration, and the State Directors of Transportation.
Conclusions
1. Neither the weather,
the position of the sun, the track nor the mechanical condition of the
train or of the school bus either caused or contributed to the collision.
The train engineer was qualified to perform his duties and was in compliance
with the hours-of-service requirements, and the bus driver was trained
and experienced to drive school buses. Neither alcohol nor drug use by
the train engineer or the school bus driver was a factor in the accident.
2. Emergency response personnel reacted promptly to the emergency and
acted effectively and efficiently at the collision site; the emergency
response efforts were well coordinated.
3. The guidance provided in the Illinois school bus driver training
curriculum about vehicle positioning on the roadway is ineffective.
4. Had the school bus driver discerned the combined visual and audible
warnings that a train were approaching, she might have had sufficient
time to recognize the hazard and move the bus before impact.
5. The methods employed by the school district to identify and evaluate
route hazards were ineffective. Furthermore, had the school district
ensured that all school bus drivers exchange information about any identified
route hazards, such as the short queuing area, the accident bus driver
might have avoided the collision.
6. Had the regular and substitute school bus drivers been monitored
during their morning routes, school officials might have been aware
that the regular school bus drivers habitually stopped on the south
side of the Algonquin Road grade crossing to wait for a green indication.
7. Illinois Department of Transportation (IDOT) had not employed sufficient
measures before the accident to prevent vehicles from encroaching on
the railroad tracks while stopped at the north side of the grade crossing.
8. During Safety Board tests, the railroad grade crossing signal system
provided 20 seconds or more warning time before the arrival of the train.
9. The installation and use of railroad and highway signal recording
devices at interconnected/preemptive grade crossings can improve opportunities
for highway and railroad personnel to determine if the signals are coordinated
and operating properly.
10. The highway traffic signal hardware (heads, controllers, masts,
posts, and loop detectors) conformed to design standards and operated
as intended, but the highway signal system did not provide sufficient
time for northbound traffic on Algonquin Road to clear the grade crossing.
11. The highway traffic signal system before the collision provided
a green indication for northbound Algonquin Road for 2 to 4 seconds
based on the post-accident testing, or for 2 to 6 seconds based on the
highway signal system programming.
12. Had a database containing grade crossing signal system information
been available after this accident, the States could have more readily
identified and then inspected specific crossings to ensure that the
signal systems posed no hazards.
13. IDOT had programmed its highway signal system without applying the
minimum warning time information from the railroad.
14. Had an effective communication system existed between IDOT and the
railroads about interconnected signal systems, IDOT, its contractors,
and the Illinois Commerce Commission might have understood that the
railroad had provided through the thumb wheel setting only the Federal
Railroad Administration required minimum of 20 seconds of warning time
before the arrival of a train at the grade crossing.
15. Had a coordinated program to ensure effective communication between
transportation modes about all aspects of grade crossing safety been
in operation, the ineffective communication between IDOT and the railroad
might never have occurred.
16. The passengers found outside the bus sustained their fatal injuries
during the initial impact sequence and not as a result of being ejected.
Probable
Cause
The
National Transportation Safety Board determines that the probable cause
of the collision was that the bus driver had positioned the school bus
so that it encroached upon the railroad tracks because of the failure
of the 1) Illinois Department of Transportation to recognize the short
queuing area on northbound Algonquin Road and to take corrective action,
2) Illinois Department of Transportation to recognize the insufficient
time of the green signal indication for vehicles on northbound Algonquin
Road before the arrival of a train at the crossing, and 3) Transportation
Joint Agreement School District 47/155 to identify route hazards and to
provide its drivers with alternative instructions for such situations.
Contributing to the accident was the failure of the
Illinois Department of Transportation and its contractors, the Illinois
Commerce Commission, and the railroads to have a communications system
that ensures understanding of the integration and working relationship
of the railroad and highway signal systems.
Safety
Recommendations
As
a result of its investigation of this accident, the National Transportation
Safety Board makes the following recommendations:
--to the U.S. Secretary of Transportation: 1. Develop a comprehensive
and periodic railroad/highway grade crossing safety inspection program
to be conducted jointly by railroads and public entitles and also require
railroads and public entities to coordinate any changes to railroad/highway
grade crossings before implementation.
2. Notify, in cooperation with the American Association of State Highway
and Transportation Officials, the National Association of County Engineers,
the American Public Works Association, the Institute of Transportation
Engineers, the Association of American Railroads, the American Short
Line Railroad Association, and the American Public Transit Association,
railroads and public entities about the importance of exchanging information
about railroad/highway grade crossings.
3. Develop a common glossary of railroad/highway grade crossing terms
and disseminate this glossary to railroads and public entities.
4. Develop a training program in the design and operation of railroad/highway
grade crossings that includes the interaction between rail and highway
signal systems. Require representatives of the railroads, public entities,
and others who design and maintain grade crossing signal systems to
complete the training program.
5. Require the use and maintenance of railroad and highway traffic signal
recording devices on all new and improved installations of railroad/highway
grade crossings that have active warning train detection systems and
are interconnected/preempted to highway signal systems. These devices
should record sufficient parameters to allow railroad and highway personnel
to readily determine that the highway signals and railroad-activated
warning devices are coordinated and operating properly. Require that
these devices be used during comprehensive and periodic joint inspections.
6. Require that existing recording devices for railroad and highway
signal systems at interconnected/preempted grade crossings be retained
or upgraded as necessary. Require that these recording devices be maintained
and that the information from these devices be used during the comprehensive
and periodic joint inspections.
--to the Federal Highway Administration: 7. Develop guidelines and amend
the Manual on Uniform Traffic Control Devices for Streets and Highways
to provide methods to delineate the area (zone) that a train, or its
cargo, or both, may occupy on the track or tracks of a railroad grade
crossing so motorists have visual reference points to ascertain whether
their vehicle is encroaching on the travel path of the train, or its
cargo, or both.
8. Disseminate safety information, in cooperation with the National
Highway Traffic Safety Administration and Operation Lifesaver, Inc.,
once guidelines are developed, to national, State, police, public service,
and safety agencies to provide a training and education module to inform
motorists of how to delineate the area (zone) that a train, or its cargo,
or both, may occupy on the track or tracks of a railroad grade crossing.
9. Cooperate with the Federal Railroad Administration in the review
and modification of the existing parameters of the national Highway-Rail
Crossing Inventory to ensure that it meets the needs of both railroad
and highway users.
--to the Federal Railroad Administration: 10. In cooperation with the
Federal Highway Administration, review and modify the existing parameters
of National Highway-Rail Crossing inventory to ensure that it meets
the needs of both railroad and highway users. Include, as a minimum,
information on highway/railroad grade crossings having preemptive or
interconnected signals. Once modified, review and update the information
annually.
--to the National Highway Traffic Safety Administration: 11. Determine
what effect school bus sound attenuation materials have on the ability
of a bus driver to discern both interior and exterior audible warnings.
12. Disseminate safety information, in cooperation with the Federal
Highway Administration, once it develops guidelines, to national, State,
police, public service, and safety agencies to provide a training and
education module to inform motorists of how to delineate the area (zone)
that a train, or its cargo, or both, may occupy on the track or tracks
of a railroad grade crossing.
--to the State of Illinois: 13. Advise school bus drivers of the circumstances
of this accident and provide the bus drivers with practical training
about vehicle positioning on the road, especially at railroad/highway
grade crossings.
--to the Illinois Department of Transportation: 14. Review and modify
the highway design for all railroad/highway grade crossings in Illinois
to ensure that vehicles have adequate space and time to clear the crossing
before the arrival of a train.
15. Train Illinois Department of Transportation personnel and contractors
involved in the design, inspection and maintenance of highway signals
at railroad/highway crossings to ensure that they understand the integration
and working relationship of the railroad and highway signal systems.
--to the Transportation Joint Agreement School District 47/155: 16.
Develop and implement a program for the identification of school bus
route hazards and routinely monitor and evaluate all regular and substitute
school bus drivers.
--to the National Association of State Directors of Pupil Transportation
Services: 17. Advise your members of the circumstances of this accident
and provide guidance about vehicle positioning on the road, especially
at railroad/highway grade crossings.
18. Encourage your members to develop and implement a program for the
identification of school bus route hazards and to routinely monitor
and evaluate all regular and substitute school bus drivers.
19. Develop guidelines for the appropriate placement of radio speakers
and use of radios on school buses and disseminate these guidelines to
your members.
20. Advise your members to consider railroad/highway grade crossing
accident histories or unusual operating characteristics when establishing
school bus routes.
21. Advise your members to check their school district buses and disable
any radio speakers located immediately adjacent to the school bus drivers'
heads.
--to the American Association of State Highway and Transportation Officials:
22. Advise your members of the circumstances of this accident and ,
in cooperation with the U.S. Department of Transportation, notify railroads
and public entities about the importance of exchanging information regarding
railroad/highway grade crossings.
--to the National Association of County Engineers: 23. Advise your members
of the circumstances of this accident and, in cooperation with the U.S.
Department of Transportation, notify railroads and public entities about
the importance of exchanging information regarding railroad/highway
grade crossings.
--to the American Public Works Association: 24. Advise your members
of the circumstances of this accident and, in cooperation with the U.S.
Department of Transportation, notify railroads and public entities about
the importance of exchanging information regarding railroad/highway
grade crossings.
--to the Institute of Transportation Engineers: 25. Advise your members
of the circumstances of this accident and in cooperation with the U.S.
Department of Transportation notify railroads and public entities about
the importance of exchanging information regarding railroad/highway
grade crossings.
--to the Association of American Railroads: 26. Advise your members
of the circumstances of this accident and, in cooperation with the U.S.
Department of Transportation, notify railroads and public entities about
the importance of exchanging information regarding railroad/highway
grade crossings.
--to the American Short Line Railroad Association: 27. Advise your members
of the circumstances of this accident and, in cooperation with the U.S.
Department of Transportation, notify railroads and public entities about
the importances of exchanging information regarding railroad/highway
grade crossings.
--to the American Public Transit Association: 28. Advise your members
of the circumstances of this accident and, in cooperation with the U.S
Department of Transportation, notify railroads and public entities about
the importance of exchanging information regarding railroad/highway
grade crossings.
--to Operation Lifesaver, Inc.: 29. Disseminate safety information,
in cooperation with the Federal Highway Administration, and the National
Highway Traffic Safety Administration, once it develops guidelines,
to national, State, police, public service, and safety agencies to provide
a training and education module to inform motorists of how to delineate
the area (zone) that a train, or its cargo, or both, may occupy on the
track or tracks of a railroad grade crossing.
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