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Safety Recommendation Details

Safety Recommendation R-19-010
Details
Synopsis: On December 18, 2017, at 7:34 a.m. Pacific standard time, southbound Amtrak (National Railroad Passenger Corporation) passenger train 501, consisting of 10 passenger railcars, a power railcar, a baggage railcar, and a locomotive at either end, derailed from a bridge near DuPont, Washington. When the train derailed, it was on its first revenue service run on a single main track (Lakewood Subdivision) at milepost 19.86. There was one run for special guests the week before the accident. Several passenger railcars fell onto Interstate 5 and hit multiple highway vehicles. At the time of the accident, 77 passengers, 5 Amtrak employees, and a Talgo, Inc., technician were on the train. Of these individuals, 3 passengers were killed, and 57 passengers and crewmembers were injured. Additionally, 8 individuals in highway vehicles were injured. The damage is estimated to be more than $25.8 million. The accident investigation focused on the following issues: individual agency responsibilities in preparation for inaugural service, multiagency participation in preparation for inaugural service, Amtrak safety on a host railroad, implementation of positive train control, training and qualifying operating crews, crashworthiness of the Talgo equipment, survival factors and emergency design of equipment, and multiagency emergency response. As a result of this investigation, the National Transportation Safety Board makes safety recommendations to the United States Secretary of Transportation, the Federal Railroad Administration, United States Department of Defense Fire and Emergency Services Working Group, the Washington State Department of Transportation, the Oregon Department of Transportation, National Railroad Passenger Corporation (Amtrak), and the Central Puget Sound Regional Transit Authority. The National Transportation Safety Board also reiterates four recommendations to the Federal Railroad Administration and reclassifies three recommendations to the Federal Railroad Administration.
Recommendation: TO THE FEDERAL RAILROAD ADMINISTRATION: Require railroads to apply their existing speed limit action plan criteria for overspeed risk mitigation to all current and future projects in the planning, design, and construction phases, including projects where operations are provided under contract.
Original recommendation transmittal letter: PDF
Overall Status: Open - Await Response
Mode: Railroad
Location: DuPont, WA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: RRD18MR001
Accident Reports: Preliminary Report Railroad Amtrak Passenger Train 501 Derailment DuPont, Washington December 18, 2017 RRD18MR001Amtrak Passenger Train 501 Derailment
Report #: RAR-19-01
Accident Date: 12/18/2017
Issue Date: 6/24/2019
Date Closed:
Addressee(s) and Addressee Status: FRA (Open - Await Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FRA
Date: 6/24/2019
Response: On May 21, 2019, the National Transportation Safety Board (NTSB) adopted its report, Amtrak (National Railroad Passenger Corporation) Passenger Train 501 Derailment, DuPont, Washington, December 18, 2017, NTSB/RAR-19/01. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. As a result of this investigation, the NTSB identified the following safety issues: • Individual agency responsibilities in preparation for inaugural service • Multiagency participation in preparation for inaugural service • Amtrak (National Railroad Passenger Corporation) safety on a host railroad • Implementation of positive train control • Training and qualifying operating crews • Crashworthiness of the Talgo equipment • Survival factors and emergency design of equipment • Multiagency emergency response Accordingly, the NTSB makes the following safety recommendations to the Federal Railroad Administration (FRA). Additional information regarding these recommendations can be found in the noted sections of the report. • Study the efficacy of how signs used in other modes of transportation may be effectively used in the railroad industry. (R-19-008) (See section 2.4.4.) • Require railroads to periodically review and update their speed limit action plans to reflect any operational or territorial operating changes requiring additional safety mitigations and to continually monitor the effectiveness of their speed limit action plan mitigations. (R-19-009) (See section 2.5.2.) • Require railroads to apply their existing speed limit action plan criteria for overspeed risk mitigation to all current and future projects in the planning, design, and construction phases, including projects where operations are provided under contract. (R-19-010) (See section 2.5.2.) • Prohibit the operation of passenger trains on new, refurbished, or updated territories unless positive train control is implemented. (R-19-011) (See section 2.5.7.) • Remove the grandfathering provision within Title 49 Code of Federal Regulations 238.206(d) and require all railcars comply with the applicable current safety standards. (R-19-012) (See section 2.6.3.) • Use your authority and compel all commuter and passenger railroads to meet the requirements outlined in Title 49 Code of Federal Regulations Part 238 without delay, such that in the event of a loss of power, adequate emergency lighting is available to allow passengers, crewmembers, and first responders to see and orient themselves, identify obstacles, safely move throughout the railcar, and evacuate safely. (R-19-013) (See section 2.7.1.) • Reevaluate existing seat securement mechanisms and their susceptibility to inadvertent rotation, to identify a means to prevent the failure of these devices to maintain seat securement. (R-19-014) (See section 2.7.4.) • Conduct research into the effectiveness of occupant protection through compartmentalization for passengers whose size (including children) is not within the current range of anthropomorphic passenger sizes in Federal Railroad Administration standards. (R-19-015) (See section 2.7.5.) Our report also classified the following previously issued safety recommendations: • Require railroads to install devices and develop procedures that will help crewmembers identify their current location and display their upcoming route in territories where positive train control will not be implemented (R-16-32) (See section 2.5.6.) Safety Recommendation R-16-32 is classified Open?Unacceptable Response. • Conduct research to evaluate the causes of passenger injuries in passenger railcar derailments and overturns and evaluate potential methods for mitigating those injuries, such as installing seat belts in railcars and securing potential projectiles. (R-16-35) (See section 2.7.5.) Safety Recommendation R-16-35 is classified Open?Unacceptable Response. • When the research specified in Safety Recommendation R-16-35 identifies safety improvements, use the findings to develop occupant protection standards for passenger railcars that will mitigate passenger injuries likely to occur during derailments and overturns. (R-16-36) (See section 2.7.5.) Safety Recommendation R-16-36 is classified Open?Unacceptable Response. The NTSB reiterates the following recommendations to the FRA: • Enact Title 49 Code of Federal Regulations Part 270, “System Safety Program,” without further delay. (R-17-17) (See section 2.5.7.) • Require railroads to install devices and develop procedures that will help crewmembers identify their current location and display their upcoming route in territories where positive train control will not be implemented (R-16-32) (See section 2.5.6.) • Conduct research to evaluate the causes of passenger injuries in passenger railcar derailments and overturns and evaluate potential methods for mitigating those injuries, such as installing seat belts in railcars and securing potential projectiles. (R-16-35) (See section 2.7.5.) • When the research specified in Safety Recommendation R-16-35 identifies safety improvements, use the findings to develop occupant protection standards for passenger railcars that will mitigate passenger injuries likely to occur during derailments and overturns. (R-16-36) (See section 2.7.5.) The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number. We encourage you to submit your response to correspondence@ntsb.gov. If your reply exceeds 20 megabytes, including attachments, please e-mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response. The attached letter from the NTSB Chairman provides information about the NTSB’s May 21, 2019, report, Amtrak (National Railroad Passenger Corporation) Passenger Train 501 Derailment, DuPont, Washington, December 18, 2017, NTSB/RAR-19/01. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (for example, R-19-017). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply exceeds 20 megabytes, including attachments, please e-mail us at the same address for instructions on how to send larger documents. Please do not submit both an electronic copy and a hard copy of the same response.