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:
- Enact Title 49 Code of Federal Regulations Part 270, System Safety Program, without further delay.
- 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:
- Establish a method to ensure that on-track protection in an active work zone is not lost during shift transfer.
- 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.
- Require supervisors to review train dispatchers’ foul time log sheets to verify whether supplemental shunting devices are being adequately applied.
- 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.
- 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.
- Work with labor to achieve full participation in all applicable safety programs.
- 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.
- 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.
- 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:
- Work with Amtrak to improve the effectiveness of all applicable safety programs.
- Work collaboratively with Amtrak to develop and implement a viable safety reporting system (for example, C3RS).
- 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)