Railroad Accident Report - Derailment of Amtrak Train No. 58

City of New Orleans
Near Flora, Mississippi
April 6, 2004

NTSB Number: RAR-05-02
NTIS Number: PB2005-916302
Adopted July 26, 2005
PDF

Executive Summary

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 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.

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 Safety Board makes safety recommendations to the Federal Railroad Administration, the Canadian National Railway Company, and Amtrak.

Recommendations

As a result of its investigation of the April 6, 2004, derailment of Amtrak's train No. 58, the City of New Orleans, near Flora, Mississippi, the National Transportation Safety Board makes the following safety recommendations:

To the Federal Railroad Administration:

Emphasize to your track inspectors the importance of enforcing a railroad's continuous welded rail program as a part of the Federal Track Safety Standards, and verify that inspectors are documenting noncompliance with the railroad's program. (R-05-05)

Establish an audit and enforcement program to verify that Amtrak complies with initial and periodic emergency preparedness training for all crewmembers systemwide, as required by 49 Code of Federal Regulations Part 239. (R-05-06)

To the Canadian National Railway Company:

Establish an audit program to verify that employees follow the current written track maintenance and inspection procedures, including rail anchoring requirements and specifically maintaining the preferred rail laying temperature. (R-05-07)

To the National Railroad Passenger Corporation (Amtrak):

Report to the Board within 90 days a schedule for training your employees who have not received emergency preparedness training as required by 49 Code of Federal Regulations Part 239. (R-05-08)