Railroad Accident Newsroom

The Federal Railroad Administration Was Not Conducting Periodic Audits Of Amtrak’s Passenger Train Emergency Preparedness Plan

About 6:33 p.m. central daylight time on April 6, 2004, northbound National Railroad Passenger Corporation (Amtrak) train No. 58 (City of New Orleans), derailed on Canadian National Railway Company railroad track near Flora, Mississippi. The entire train, consisting of one locomotive, one baggage car, and eight passenger cars, derailed near milepost 196.5 while traveling about 78 mph. The train was carrying 61 passengers and 12 Amtrak employees. The derailment resulted in 1 fatality, 3 serious injuries, and 43 minor injuries. The equipment costs associated with the accident totaled about $7 million.The safety issues addressed in this report are: 

The Canadian National Railway Company’s continuous welded rail maintenance and inspection procedures and standards; Amtrak’s emergency response training of its employees; and The Federal Railroad Administration’s oversight of continuous welded rail maintenance programs and Amtrak’s emergency response training of its employees.  

Other items discussed in this report include: 

Establishment of incident command during emergency response; and Operation of handles to remove emergency windows to allow egress from damaged cars.  

As a result of its investigation of this accident, the National Transportation Safety Board makes safety recommendations to the Federal Railroad Administration, the Canadian National Railway Company, and Amtrak. 

Amtrak train No. 58 and its related equipment functioned as intended and did not cause the derailment.  

The operation of the train was not a factor in the accident. The inadequately restrained east rail lifted out of the tie plates because of expansion caused by warm temperatures resulting in the rail shifting and the gage widening, causing the wheels of the train to drop between the rails.  

Although the Canadian National Railway Company had written instructions for maintaining continuous welded rail and preventing track buckling, track employees at multiple levels did not follow or ensure adherence to these instructions.  

Hadthe employees who maintained the track at the accident site followed the written procedures the rail shift condition likely would not have occurred.  

Although a Federal Railroad Administration preaccident inspection identified track deficiencies, the Federal Railroad Administration’s oversight was not effective in ensuring corrective action by the Canadian National Railway Company. 

Although it was not a factor in this accident, Amtrak was not assuring that all of its crewmembers received emergency preparedness training.  

The Federal Railroad Administration was not conducting periodic audits of Amtrak’s passenger train emergency preparedness plan to ensure that all crewmembers were receiving the required emergency preparedness training.  

The handle on an emergency window on the sleeper car was found to have failed.  

PROBABLE CAUSE 

The National Transportation Safety Board determines that the probable cause of Amtrak’s City of New Orleans accident on April 6, 2004, near Flora, Mississippi, was the failure of the Canadian National Railway Company to properly maintain and inspect its track, resulting in a rail shift and the subsequent derailment of the train, and the Federal Railroad Administration’s ineffective oversight to ensure the proper maintenance of the track by the railroad.