NTSB Issues Scathing Final Report on Amtrak Crash

The board's conclusions, recommendations, and statements from individual board members are riveting, starting on page 120 of the report. They cite multiple failures by the Federal Railroad Administration, Amtrak, the Washington State Department of Transportation, and the Central Puget Sound Regional Transit Authority.

The National Transportation Safety Board released its final report on the Dec. 18, 2017, crash of Amtrak passenger train 501 when it derailed from a bridge near DuPont, Wash. Several passenger railcars fell onto Interstate 5 and hit highway vehicles. Among the 77 passengers, five Amtrak employees, and a Talgo, Inc., technician who were on the train, three passengers died and 57 passengers and crew members were injured. Eight people in highway vehicles also were injured. The reported states that the damage is estimated to be more than $25.8 million.

The board's conclusions, recommendations, and statements from individual board members are riveting, starting on page 120 of the report. They cite multiple failures by the Federal Railroad Administration, Amtrak, the Washington State Department of Transportation, and the Central Puget Sound Regional Transit Authority.

NTSB Vice Chairman Bruce Landsberg filed a concurring statement on June 3, 2019, that is included in the report following the recommendations. "There was a Titanic-like complacency and certainty exhibited by those tasked with the safety, operation and management of the Point Defiance Bypass rail line before the revenue service started in 2017," he wrote. "Like the Titanic, the crash happened on the very first passenger run. The term 'accident' is inappropriate because that implies that this was an unforeseen and unpredictable event. It was anything but unforeseeable. The NTSB has been investigating overspeed derailments around curves for decades. Likewise, NTSB has made recommendations to the Federal Railroad Administration (FRA) and to the railroads to implement Positive Train Control (PTC) for decades."

Landsberg wrote that the "engineer's failure was the final link in a very long chain of mismanagement events. The root cause was extremely lax safety oversight, unclear responsibility, and poor training. Railroad management and safety implementation were lacking at almost every level. . . . Multiple agencies were involved but somehow missed critical factors. By Sound Transit's own Safety and Security Management Plan (SSMP), the curve was deemed an unacceptable safety risk without implementation of PTC. Yet apparently, senior management signed off with no mitigations in place. Who's accountable?"

"Finally, it's way past time for Congress to stop granting exemptions and exceptions to a law that was passed in 2008 requiring full implementation of PTC on passenger routes by 2015," he added. "It's also way past time for many railroads and their regulatory authorities to take their management and safety oversight responsibility seriously."

The board determined that the probable cause of the derailment was Central Puget Sound Regional Transit Authority's failure to provide an effective mitigation for the hazardous curve without positive train control in place, which allowed the Amtrak engineer to enter the 30 mph curve at too high of a speed due to his inadequate training on the territory and inadequate training on newer equipment. Contributing to the accident was the Washington State Department of Transportation's decision to start revenue service without being assured that safety certification and verification had been completed to the level determined in the preliminary hazard assessment, and also the Federal Railroad Administration's decision to permit railcars that did not meet regulatory strength requirements to be used in revenue passenger service, resulting in 1) the loss of survivable space and 2) the failed articulated railcar-to-railcar connections that enabled secondary collisions with the surrounding environment, causing severe damage to railcar-body structures which then failed to provide occupant protection, resulting in passenger ejections, injuries, and fatalities.

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OH&S Digital Edition

  • OHS Magazine Digital Edition - July August 2019

    July/August 2019

    Featuring:

    • CHEMICAL SAFETY TRAINING
      Getting It Right
    • PROTECTIVE APPAREL
      Navigating Standards to Match Your Hazards
    • CONSTRUCTION SAFETY
      Just Add Water
    • FACILITY SAFETY
      Creating Safe Facilities
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