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Palmetto (89) vs. Backhoe in Chester, PA; 2 fatalities 4/3/16


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#41 CNJRoss

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Posted 26 January 2017 - 11:39 PM

The Inquirer, Philadelphia, PA 1/26/17:
 

'Oh! Man!' the foreman cried, minutes after an Amtrak train killed two workers in Chester

 

 

It was 7:51 a.m. last April 3, and an Amtrak train had just derailed in Chester, killing two workers on the tracks. The foreman on duty called a dispatcher, trying to grasp how a train could have been traveling on tracks he believed to be secure. They weren't, the dispatcher said. The tracks had been opened for train traffic less than a half-hour before.

 

“Oh my gosh!" the foreman is quoted as saying in transcripts from radio and phone communications after the impact. "You’ve got to be kidding me! Oh! Man!”

 

New documents released Thursday by the National Transportation Safety Board describe the shock and confusion of workers as a train slammed into a backhoe on tracks that should have been closed to traffic. The documents also show that the engineer and the two workers  tested positive for drugs. The backhoe operator, Joe Carter, and a supervisor, Peter Adamovich, two veteran Amtrak employees, were killed. 

 

SNIP

 

The docket also revealed that the engineer on Amtrak Train 89, Alex Hunter, 47, tested positive for marijuana. He also tested positive for opioids, but that was the result of a morphine injection during his treatment after the crash. Amtrak reported Thursday that Hunter is no longer an employee with the railroad. The engineer acted attentive, responding to alerts and keeping his eyes forward in the minutes before the crash, according to the docket.

 

Drugs were also found in the systems of both men who died in the crash. Carter, 61, tested positive for cocaine, and Adamovich, 59, tested positive for codeine, oxycodone, and morphine. The document stated Adamovich did not report using medications or having chronic medical conditions.

 

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Edited by CNJRoss, 26 January 2017 - 11:51 PM.
Added 2 paragraphs with drug test information.


#42 CNJRoss

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Posted 26 January 2017 - 11:44 PM

NTSB news release:

 
Chester, Pennsylvania Rail Accident Investigation Docket Opened
1/26/2017

 

​WASHINGTON — The National Transportation Safety Board Thursday opened the docket for its investigation of a  2016 Amtrak passenger train accident near Chester, Pennsylvania.

 

Amtrak train 89 struck a back hoe used by a maintenance crew performing scheduled track work near Chester, April 3, 2016.  Two maintenance workers were killed and 41 persons aboard the train were treated for injuries.

 

The accident docket includes investigative reports, the temporary speed restrictions, and related interviews. The docket contains only factual information collected by NTSB investigators, and does not provide analysis, findings, recommendations or probable cause determinations.  No conclusions about how or why an accident occurred should be drawn from the docket.  Opening the docket affords those with a need and desire for its contents the opportunity to review the factual information gathered in the investigation of an accident.  Any analysis, findings, recommendations, or probable cause determinations related to the accident will be issued by the Board at a later date.

 

To view the docket and its contents visit http://go.usa.gov/x97VP.

 

 



#43 KevinKorell

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Posted 10 May 2017 - 12:06 PM

Philadelphia, PA Inquirer, 5/9/17:

 


 

Amtrak fires rail worker over Chester train derailment

 

An Amtrak rail worker was fired Tuesday for his part in a 2016 train derailment in Chester that killed two men working on the tracks.

 

Update



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#44 KevinKorell

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Posted 11 October 2017 - 12:28 AM

Washington, DC Post, 10/10/17:

 


 

Amtrak workers and engineer killed in crash had all used drugs, including opioids and cocaine

 

Two Amtrak maintenance workers were using opioids or cocaine when they were struck and killed south of Philadelphia last year by a passenger train whose engineer had marijuana in his system, according to federal officials.

 

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Kevin Korell


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Lakewood, NJ


#45 CNJRoss

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Posted 15 November 2017 - 03:58 PM

NTSB press release:

 
Ignored Safety Procedures, Fractured Safety Program Led to Fatal Amtrak Derailment
 
 

WASHINGTON (Nov. 14, 2017) — The National Transportation Safety Board determined Tuesday the April 3, 2016, derailment of Amtrak train 89 near Chester, Pennsylvania was caused by deficient safety management across many levels of Amtrak and the resultant  lack of a clear, consistent and accepted vision for safety.

 

A backhoe operator and a track supervisor were killed, and 39 people were injured when Amtrak train 89, traveling on the Northeast Corridor from Philadelphia to Washington on track 3, struck a backhoe at about 7:50 a.m. The train engineer saw equipment and people working on and near track 3 and initiated emergency braking that slowed the train from 106 mph to approximately 99 mph at the time of impact.

 

The NTSB also determined allowing a passenger train to travel at maximum authorized speed on unprotected track where workers were present, the absence of shunting devices, the foreman’s failure to conduct a job briefing at the start of the shift, all coupled with the numerous inconsistent views of safety and safety management throughout Amtrak, led to the accident.

 

“Amtrak’s safety culture is failing, and is primed to fail again, until and unless Amtrak changes the way it practices safety management,” said NTSB Chairman Robert L. Sumwalt. “Investigators found a labor-management relationship so adversarial that safety programs became contentious at the bargaining table, with the unions ultimately refusing to participate.”

 

The NTSB also noted the Federal Railroad Administration’s failure to require redundant signal protection, such as shunting, for maintenance-of-way work crews contributed to this accident.

 

Post-accident toxicology determined that the backhoe operator tested positive for cocaine, and the track supervisor and tested positive for codeine and morphine.   The locomotive engineer tested positive for marijuana. The NTSB determined that while drug use was not a factor in this accident, it was symptomatic of a weak safety culture at Amtrak.

 

As a result of this investigation, the NTSB issued 14 safety recommendations including nine to Amtrak.

 

The NTSB also made two safety recommendations to the Federal Railroad Administration, and three safety recommendations were issued to the Brotherhood of Maintenance of Way Employees Division, American Railway and Airway Supervisors Association, Brotherhood of Locomotive Engineers and Trainmen, and Brotherhood of Railroad Signalmen.

 

The abstract of the NTSB’s final report, that includes the findings, probable cause and safety recommendations is available online at https://go.usa.gov/xnWpg.  The final report will be publicly released in the next several days.

 

The webcast of the board meeting for this investigation is available for 90 days at http://ntsb.capitolconnection.org/.

 

 

 



#46 CNJRoss

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Posted 15 November 2017 - 04:05 PM

NTSB Railroad Accident Report 17/02 (excerpt):

 

 

NATIONAL TRANSPORTATION SAFETY BOARD

Public Meeting of November 14, 2017

(Information subject to editing)

 

 

Amtrak Train Collision with 

Maintenance-of-Way Equipment

Chester, Pennsylvania

April 3, 2016

NTSB/RAR-17/02

 

This is a synopsis from the NTSB’s report and does not include the Board’s rationale for the conclusions, probable cause, and safety recommendations. NTSB staff is currently making final revisions to the report from which the attached conclusions and safety recommendations have been extracted. The final report and pertinent safety recommendation letters will be distributed to recommendation recipients as soon as possible. The attached information is subject to further review and editing to reflect changes adopted during the Board meeting.

 

Executive Summary

 

On April 3, 2016, about 7:50 a.m. eastern daylight time, southbound Amtrak train 89 (train 89) struck a backhoe with a worker inside at milepost 15.7 near Chester, Pennsylvania. The train was authorized to operate on main track 3 (track 3) at the maximum authorized speed of 110 mph. Beginning on the morning of April 1, Amtrak had scheduled track-bed restoration―ballast vacuuming—at milepost 15.7 on track 2 on the Philadelphia to Washington Line. Track 2 had to be taken out of service between control points Baldwin (milepost 11.7) and Hook (milepost 16.8) for the 55 hour duration of the project. As train 89 approached milepost 15.7, the locomotive engineer saw equipment and workers on and near track 3 and initiated an emergency brake application. The train speed was 106 mph before the emergency brake application and 99 mph when it struck the backhoe. Two roadway workers were killed, and 39 other people were injured. Amtrak estimated property damages to be $2.5 million.

 

SNIP

 

PROBABLE CAUSE

 

The National Transportation Safety Board determines that the probable cause of the accident was the unprotected fouled track that was used to route a passenger train at maximum authorized speed; the absence of supplemental shunting devices, which Amtrak required but the foreman could not apply because he had none; and the inadequate transfer of job site responsibilities between foremen during the shift change that resulted in failure to clear the track, to transfer foul time, and to conduct a job briefing. Allowing these unsafe actions to occur were the inconsistent views of safety and safety management throughout Amtrak’s corporate structure that led to the company’s deficient system safety program that resulted in part from Amtrak’s inadequate collaboration with its unions and from its failure to prioritize safety. Also contributing to the accident was the Federal Railroad Administration’s failure to require redundant signal protection, such as shunting, for maintenance-of-way work crews who depend on the train dispatcher to provide signal protection, prior to the accident.

 

 

RECOMMENDATIONS

 

New Recommendations 

 

As a result of this investigation, the National Transportation Safety Board makes safety recommendations to the Federal Railroad Administration, Amtrak, Brotherhood of Maintenance of Way Employes Division, American Railway and Airway Supervisors Association, Brotherhood of Locomotive Engineers and Trainmen, and Brotherhood of Railroad Signalmen. The National Transportation Safety Board also reiterates a recommendation to the Federal Railroad Administration.

 

To the Federal Railroad Administration:

  1. Enact Title 49 Code of Federal Regulations Part 270, System Safety Program, without further delay.  
  2. Require railroads to install technology on hi-rail, backhoes, other independently operating pieces of maintenance-of-way equipment and on the leading and trailing units of sets of maintenance-of-way equipment operated by maintenance workers to provide dispatchers and the dispatch system an independent source of information on the locations of this equipment to prevent unauthorized incursions by trains onto sections of track where maintenance activities are taking place in accordance with the Congressional mandate under the Rail Safety Improvement Act of 2008.  

 

 

To Amtrak:

  1. Establish a method to ensure that on-track protection in an active work zone is not lost during shift transfer.
  2. Develop and implement an engineering safety procedure for preparing site-specific work plans for maintenance projects on the Northeast Corridor main line tracks spanning multiple shifts or multiple workdays to reduce or mitigate the inherent risks of maintenance-of-way work in a high-speed train operations environment.
  3. Require supervisors to review train dispatchers’ foul time log sheets to verify whether supplemental shunting devices are being adequately applied. 
  4. Revise its train dispatcher rules so that potentially distracting activities, such as making personal telephone calls, are not allowed while dispatchers are on duty and responsible for safe train operations. 
  5. Conduct a risk assessment for all engineering projects; use the results to issue significant speed restrictions for trains passing any engineering project that involves safety risks for workers, equipment, or the traveling public, such as ballast vacuuming, as part of a risk-mitigation policy. 
  6. Work with labor to achieve full participation in all applicable safety programs.
  7. Work collaboratively with labor to develop and implement a viable safety reporting system (for example, C3RS); ensure that employees do not experience reprisal for using the system; respond quickly on the data collected; and communicate any resulting safety improvements to all employees.
  8. Work collaboratively with labor in an effort to develop a comprehensive safety management system program that complies with pending Federal Railroad Administration regulation Title 49 Code of Federal Regulations Part 270, System Safety Program, and that vitalizes safety goals and programs with executive management accountability; incorporates risk management controls for all operations affecting employees, contractors, and the traveling public; improves continually through safety data monitoring and feedback; and is promoted at all levels of the company.
  9. Once [the previous safety recommendation] is completed, implement the safety management system program throughout the company with resources sufficient to ensure that all levels of management and all labor unions involved with Amtrak operations accept and comply with the system.

 

To Brotherhood of Maintenance of Way Employes Division, American Railway and Airway Supervisors Association, Brotherhood of Locomotive Engineers and Trainmen, and Brotherhood of Railroad Signalmen:

  1. Work with Amtrak to improve the effectiveness of all applicable safety programs.
  2. Work collaboratively with Amtrak to develop and implement a viable safety reporting system (for example, C3RS).
  3. Work collaboratively with Amtrak in an effort to develop a comprehensive safety management system program that complies with pending Federal Railroad Administration regulation Title 49 Code of Federal Regulations Part 270, System Safety Program, and that vitalizes safety goals and programs with executive management accountability; incorporates risk management controls for all operations affecting employees, contractors, and the traveling public; improves continually through safety data monitoring and feedback; and is promoted at all levels of the company.

 

Previously Issued Recommendation Reiterated in This Report To the Federal Railroad Administration:

Require redundant signal protection, such as shunting, for maintenance-of-way work crews who depend on the train dispatcher to provide signal protection. (R-08-6)

 

 

Amtrak Train Collision with  Maintenance-of-Way Equipment Chester, Pennsylvania April 3, 2016 NTSB/RAR-17/02



#47 CNJRoss

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Posted 15 November 2017 - 04:10 PM

Progressive Railroading,11/15/17:

 
NTSB: Amtrak's weak safety culture led to fatal derailment

 

g47977-Amtrak-Chester-derailment.jpg

The derailment occurred April 3, 2016, in Chester, Pennsylvania, when an Amtrak train struck a backhoe, killing the backhoe operator and a track supervisor. Photo – NTSB

 

An Amtrak derailment that killed two track maintenance workers last year was caused by "deficient safety management" across the railroad, which resulted in a lack of a "clear, consistent and accepted vision for safety," the National Transportation Safety Board (NTSB) announced yesterday.

The derailment occurred April 3, 2016, in Chester, Pennsylvania, when an Amtrak train traveling from Philadelphia to Washington, D.C., struck a backhoe, killing the backhoe operator and a track supervisor. Thirty-nine other people were injured.

 

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#48 Sloan

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Posted 27 November 2017 - 03:07 PM

 

David Schanoes of Railway Age commentary: Culture Wars Part 1

 

I spent three hours viewing the video archive of the Nov. 14, 2017 National Transportation Safety Board meeting convened to review and approve the findings, probable cause and safety recommendations developed from NTSB investigation into the April 3, 2016 collision of Amtrak 89 with M/W equipment at Chester, Pa., on the Northeast Corridor.

http://www.railwayag...html?channel=00

 

This reminds me of a similar, but non-lethal, incident described in a memoir of Pennsylvania Railroad steam locomotive engineer, Oscar Orr.

 

https://www.amazon.c...=set up running

 

In 1945, Oscar Orr had a coal drag coming out of Lock Haven, PA at 60 MPH.  Dispatcher had forgotten to tell him of a track gang replacing ties on a blind curve with an escarpment on one side.  The gandy dancers had six jacks on the cliff-side rail and were getting ready to pull spikes.  When they heard the distinctive K-4 sound approaching, they scrambled up the side of the escarpment to get out of the way.  Oscar went into emergency, but the train's momentum carried it over the jacks, breaking all of them!  Fortunately, there was no derailment.  Later the dispatcher apologized to Oscar for the screw-up; and, according to the memoir, there was no disciplinary action against anyone.  

 

Sloan



#49 CNJRoss

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Posted 07 December 2017 - 11:23 AM

Railway Age, 12/6/17:
 

Guest Blog: NTSB missed the mark

 

Written by  Chip Kraft, for Railway Age

 

The NTSB analysis of the 2016 Amtrak backhoe accident on the Northeast Corridor at Chester, Pa., that killed two m/w workers and injured 39 has missed the mark. This incident is by no means the first of its kind.

 

NTSB issued Safety Recommendation R-08-06, after a 2007 accident near Woburn, Mass., in which two Massachusetts Bay Transportation Authority (MBTA) maintenance-of-way employees died: “Require redundant signal protection, such as shunting, for maintenance-of-way work crews who depend on the train dispatcher to provide signal protection.”

 

In 2013, NTSB reiterated Safety Recommendation R-08-06 to FRA after an accident in which a Metro-North maintenance-of-way employee was struck and killed by a train in Connecticut.

And now, as a result of the 2016 accident—the third accident in less than a decade under remarkably similar circumstances—NTSB reiterated the same recommendation a third time. Stronger action is needed to prevent future incidents, particularly in Positive Train Control (PTC) territory, or else the 2016 accident most likely will not be the last.

 

As part of R-08-6, the mention of shunting as part of the recommendation is, unfortunately, a serious distraction. Shunting is not considered failsafe by the railroad industry, and the practice can cause other problems. From an FRA report on roadway worker protection (downloadable at the link below):

 

Chip Kraft is Director of Operations Planning at Transportation Economics & Management Systems Inc.

 

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#50 KevinKorell

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Posted 01 September 2018 - 07:39 PM

Philadelphia, PA Inquirer, 8/31/18:

 


 

Chester’s Amtrak crash leads to new safety protections for rail workers nationwide

 

 

It's been more than two years since an Amtrak train killed two track workers in Chester. Now, that event — and the harsh criticism from federal authorities that followed — has led to new safety standards designed to protect workers doing track maintenance.

 

 

Read this.



Kevin Korell


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Lakewood, NJ





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