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Safety Recommendation Details

Safety Recommendation R-19-022
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 NATIONAL RAILROAD PASSENGER CORPORATION (AMTRAK): Implement a formal, systematic approach to developing training and qualification programs to identify the most effective strategies for preparing crewmembers to safely operate new equipment on new territories.
Original recommendation transmittal letter: PDF
Overall Status: Open - Initial Response Received
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: Amtrak (National Railroad Passenger Corporation) (Open - Initial Response Received)
Keyword(s):

Safety Recommendation History
From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 6/25/2019
Response: -From Richard Anderson, President and Chief Executive Officer: Amtrak took immediate action in the wake of the derailment to establish a centralized process for the oversight of route qualification. As noted in Amtrak's submission to the docket these efforts have culminated in the adoption of a new Engineer Route Qualification protocol that governs how crews will be trained and evaluated on new territory. The type and amount of training required, including a minimum number of training runs performed by a Designated Supervisor of Locomotive Engineers (OSLE) or On the Job Training Instructor (OJTI) reflects a careful risk assessment of the specific route in question. This assessment is overseen by the Compliance, Certification and Quality Assurance division within the Amtrak's Safety organization. In the case of the Pt. Defiance Bypass, Amtrak simulators were upgraded with route specific characteristics in early 2019. The qualification program requirements include physical characteristic training, oral and written rules examinations and simulator assessments. Exam content is developed and approved by the office of the System General Road Foreman. In line with the aforementioned upgrades to the simulation program, Engineers will perform multiple runs in the territory in both daylight and nighttime conditions. After successful completion of the simulation program, engineers are required to operate a minimum of six round trips over the route and receive a final round trip evaluation with a qualified OSLE. Conductors are required to pass written and oral examinations in addition to completion of at least two head end observation trips and at least one observation trip in the body of the train. Amtrak first published a Siemens Charger diesel quick reference guide on 4/ 17/2017. This guide was accompanied by a System General Road Foreman Notice (SGRFN) which detailed the operational characteristics and protocols for the Charger Locomotive. This notice has undergone several updates since. Earlier this year, Amtrak issued a dedicated "Siemens SC-44 Charger Diesel Overspeed Condition" advisory to all crew bases that operate the Charger diesel locomotive as a training tool that specifically addresses the "Overspeed" alarm. Both documents are available to all crews and are used during training. Enclosed for reference purposes are the SGRFN which details the information for the Charger Locomotive. This notice serves as an interim mitigation while more formal curriculum is being developed. Moving forward, formal curriculum for each new locomotive that Amtrak is operating will be employed. This curriculum will use videos, Power Point presentations and a hands-on module during which locomotive engineers are getting trained on the layout of the locomotive, normal operation and troubleshooting of the locomotive. This training also will include using actual equipment, and ultimately, simulators. In order to be considered qualified on the equipment, locomotive engineers must complete the classroom portion of the training and satisfactorily operate the new equipment during an evaluation ride with a qualified OSLE over a distance of at least I 00 miles. Lastly, Amtrak has developed and is implementing a strategic plan to maximize the use of simulators in training, qualification, and certification of Amtrak employees. Amtrak is upgrading the current simulator program and hardware to include route specific software and to emulate the equipment type and associated operating characteristics. This substantial increase in the fidelity of simulation will enhance the availability of training opportunities in a controlled environment.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 6/24/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge your organization to act on the safety recommendations in this letter because we believe your organization can help reduce the risk of future accidents. For more information about NTSB and our recommendation process, please see the attached one-page summary. On May 21, 2019, the 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 Amtrak (National Railroad Passenger Corporation). Additional information regarding these recommendations can be found in the noted sections of the report. • • Ensure operating crewmembers demonstrate their proficiency on the physical characteristics of a territory by using all resources available to them, including: in-cab instruments, signage, signals, and landmarks; under daylight and nighttime conditions; and during observation rides, throttle time, and written examinations. (R-19-019) (See section 2.4.1.) • • Revise your classroom and road training program to ensure that operating crews fully understand all locomotive operating characteristics, alarms, and the appropriate response to abnormal conditions. (R-19-020) (See section 2.4.2.) • • Require that all engineers undergo simulator training before operating new or unfamiliar equipment (at a minimum, experience and respond properly to all alarms), and when possible, undergo simulator training before operating in revenue service in a new territory and experience normal and abnormal conditions on that territory. (R-19-021) (See section 2.4.2.) • • Implement a formal, systematic approach to developing training and qualification programs to identify the most effective strategies for preparing crewmembers to safely operate new equipment on new territories. (R-19-022) (See section 2.4.3.) • • Work with host railroads and states that own infrastructure over which you operate to conduct a comprehensive assessment of the territories to ensure that necessary wayside signs and plaques are identified, highly conspicuous, and strategically located to provide operating crews the information needed to safely operate their trains. (R-19-023) (See section 2.4.4.) • • Conduct training that specifies and reinforces how each crewmember, including those who have not received their certifications or qualifications, may be used as a resource to assist in establishing and maintaining safe train operations. (R-19-024) (See section 2.4.5.) • • Update your safety review process to ensure that all operating documents are up to date and accurate before initiating new or revised revenue operations. (R-19-025) (See section 2.5.4.) • • Incorporate all prerevenue service planning, construction, and route verification work into the scope of your corporate-wide system safety plan, including your rules and policies, risk assessment analyses, safety assurances, and safety promotions. (R-19-026) (See section 2.5.7.) • Work collaboratively with all host railroads and states that own infrastructure over which you operate in an effort to develop a comprehensive safety • management system program that meets or exceeds the pending Federal Railroad Administration regulation, Title 49 Code of Federal Regulations Part 270, “System Safety Program.” (R-19-027) (See section 2.5.7.) • • Conduct risk assessments on all new or upgraded services that occur on Amtrak-owned territory, host railroads, or in states that own infrastructure over which you operate. (R-19-028) (See section 2.5.7.) • • Develop policies for the safe use of child safety seats to prevent uncontrolled or unexpected movements in passenger trains and provide customers with guidance for securing these child safety seats. (R-19-029) (See section 2.7.5.) The NTSB also makes the following safety recommendation to the Washington State Department of Transportation, Amtrak (National Railroad Passenger Corporation), and the Oregon Department of Transportation. • • Develop and implement a program by which all railcar seats that are designed to rotate be checked for proper positioning and securement in place before the railcar can be placed into or returned to passenger carrying service. (R-19-018) (See section 2.7.4.) • 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 (for example, R-19-019). 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 National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. • 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. For more information about NTSB and our recommendation process, please see the attached one-page summary. • 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-19-019). 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.