NTSB cites lack of safety culture in Chester, Pa., derailment

Written by Mischa Wanek-Libman, editor
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Damage is seen on the front of the Amtrak locomotive that struck a backhoe on April 3, 2016.
NTSB

The National Transportation Safety Board (NTSB) said ignored safety procedures and a fractured safety program are to blame for the April 3, 2016, derailment of Amtrak train 89 near Chester, Penn.

 

NTSB says the accident, which killed a backhoe operator and a track supervisor and left 39 people injured, was caused by “deficient safety management across many levels of Amtrak and the resultant lack of a clear, consistent and accepted vision for safety.”

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.

The derailment occurred when Train 89 was traveling on the Northeast Corridor from Philadelphia to Washington, D.C., on track 3 and 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 noted the Federal Railroad Administration’s (FRA) failure to require redundant signal protection, such as shunting, for maintenance-of-way work crews contributed to this accident.

While the NTSB determined that drug use was not a factor in the accident, it did note that post-accident toxicology determined that the backhoe operator tested positive for cocaine, the track supervisor tested positive for codeine and morphine and the locomotive engineer tested positive for marijuana.

The NTSB says that the presence of employees on duty who were unable to pass a drug test highlights another failure to prioritize safety. The U.S. Department of Transportation issued a final rule Nov. 13 that expanded the drug testing panel required of USDOT-regulated employers to include certain semi-synthetic opioids.

“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.”

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

In a statement regarding the NTSB findings, Amtrak said:

“Safety is a core value – for our passengers and our employees – and we are committed to operating our nationwide network of services safely, effectively and efficiently. We’ve been in the process of transforming our safety culture since this incident. In the 19 months since the Train 89 event, we have taken a series of actions to improve workplace safety at Amtrak – including the implementation of many of the actions discussed by the NTSB.

“We have a deep sense of obligation to our customers and employees. When a customer buys a ticket from us, or when an employee chooses to come work for us, we have a responsibility to keep them safe. Day in and day out, we work hard to live up to this obligation. We have a team of 20,000 employees who understand that safety is our No. 1 priority, and together we safely operate more than 500 trains across our 21,000-mile network every day.”

The railroad also outlined several steps it had taken since the accident and continues to take to improve its safety program.

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