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Safety Recommendation Details

Safety Recommendation R-19-027
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): 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.”
Original recommendation transmittal letter: PDF
Overall Status: Open - Initial Response Received
Mode: Railroad
Location: DuPont, WA, United States
Is Reiterated: Yes
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: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 9/30/2019
Response: Reiterated in the Railroad Accident Report RAR-19-02: Amtrak Passenger Train Head-on Collision With Stationary CSX Freight Train Cayce, South Carolina, February 4, 2018, adopted Jul 23, 2019, published on September 30, 2019, notation number 59351 and accident number RRD18MR003. 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 July 23, 2019, report Amtrak Passenger Train Head-on Collision With Stationary CSX Freight Train, Cayce, South Carolina, February 4, 2018, NTSB/RAR-19/02. The details of this accident investigation and the resulting safety recommendation 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 recommendation by number (for example, R-19-27). 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. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. 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 Amtrak (National Railroad Passenger Corporation) to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. This letter provides information about our July 23, 2019, report Amtrak Passenger Train Head-on Collision With Stationary CSX Freight Train, Cayce, South Carolina, February 4, 2018, NTSB/RAR-19/02. 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, we identified the following safety issues: • The medical examination process for railroad employees. • The actions and responsibilities of the train crew handling switches. • The CSX Transportation efficiency testing program and staffing. • Operations during signal suspensions. • Implementation of a safety management system by Amtrak to assess and mitigate risks for operation on host railroads. • Occupant protection in passenger railcars. Accordingly, the NTSB reiterates the following safety recommendation to Amtrak. Additional information regarding this reiterated recommendation can be found in the noted section of the report. • 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-19-27) (See section 2.6.4.) The NTSB is vitally interested in this recommendation because it is 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 this recommendation. When replying, please refer to the safety recommendation by number (for example, R-19-27). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply, including attachments, exceeds 20 megabytes, 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. 2.6.4 Amtrak Safety Management on Host Railroads The contributing factors surrounding the accident in Cayce present numerous examples of Amtrak’s inability to control or influence the management of safety on the host railroad. When operating over the territory of a host railroad Amtrak is subjected to the risk mitigation strategies implemented by that host. Although there is a host railroad agreement in place between Amtrak and the host railroad, this agreement does not establish the parameters for safe operations and a consistent level of risk mitigation from host railroad to host railroad. Unfortunately, this accident is just one of several that are discussed below that have occurred recently where Amtrak has demonstrated its inability to control or influence the management of safety on the host railroad. On October 5, 2015, at 10:22 a.m., southbound Amtrak passenger train 55, derailed at MP 65.2 on a single main track after striking a rock pile that fouled the right of way on the New England Central Railroad (NECR) near Northfield Vermont. The collision and subsequent derailment resulted in the locomotive and first coach car derailing and sliding down an embankment. Three additional coach cars derailed but remained upright and in-line near the track. This accident highlighted that, although Amtrak utilized a hazard management program on its owned and operated territory through its SSPP, this program was not applicable on a host railroad. The Amtrak SSPP hazard management program established a methodology for determining risk and the mitigation of this risk; the risks addressed by Amtrak included rock fall and rockslide areas along the Northeast Corridor and Harrisburg Line. In contrast, although the NECR had a safety program, at the time of the accident, the NECR did not have a formalized hazard management and assessment program as it pertains to rock fall risk management and mitigation (NTSB 2017a). On March 14, 2016, at 12:02 a.m. central daylight time, Amtrak passenger train 4 derailed near MP 372.9 in the vicinity of Cimarron, Kansas. This Los Angeles to Chicago train consisted of 2 locomotives and 10 cars. The accident occurred off of Amtrak territory where Amtrak was hosted by BNSF Railway. A runaway feed truck from an adjacent feedlot impacted the railroad tracks and pushed the tracks out of alignment. At the location of the accident, there were no protective barriers or fencing placed along the right of way to prevent this undesirable intrusion (NTSB 2017c). Along the Amtrak-owned and Amtrak-operated Northeast Corridor and Harrisburg line, Amtrak implemented an intrusion prevention strategy to develop standards and install fencing and barriers to reduce the risk of vehicle intrusion onto the right of way.54 On December 18, 2017, at 7:33 a.m., Pacific standard time, southbound Amtrak passenger train 501, consisting of a leading locomotive and a trailing locomotive, a power car, 10 passenger railcars, and a baggage car, traveling at 78 mph, derailed from a highway overpass near DuPont, Washington. When the train derailed, it was on its first regular passenger service trip on a single main track (Lakewood subdivision) at MP 19.86. The lead locomotive, the power car, and two passenger railcars derailed onto Interstate 5. Fourteen highway vehicles came into contact with the derailed equipment. At the time of the accident, 77 passengers, 5 Amtrak employees, and a Talgo Incorporated technician were on the train. Of these individuals, 3 passengers were killed, and 57 passengers and crewmembers were injured. Eight individuals in highway vehicles were also injured. Following the Amtrak train 501 derailment in DuPont, Washington, Amtrak officials developed a risk assessment process to be used to evaluate the risks to Amtrak operations over a host railroad. The process includes utilizing expertise from Amtrak’s System Safety Office and local transportation management officials. Since its development, according to Amtrak, this risk assessment process has been used 30 times by Amtrak. These accidents highlight the significant difference in the approach to managing safety on Amtrak-owned and Amtrak-operated territory versus that of a host’s railroad. Amtrak passengers should not be exposed to different levels of safety management based on who owns the tracks. Amtrak relies on host railroads to meet the minimum federal safety standards (49 CFR Parts 200 - 299) to ensure safe operations of Amtrak trains. However, in his interview with NTSB discussed in Section 1.15.1.4 in this report, Amtrak’s CEO noted that on its own territory, Amtrak aims to meet and exceed this standard by not only meeting the FRA’s minimum safety standards but also through the use of a voluntary SSPP and more recently in response to NTSB Safety Recommendations R-17-26 and R-17-27. As a result of similar findings in the investigation of the accident in DuPont, Washington, the NTSB issued Safety Recommendation R-19-27 to Amtrak: Work collaboratively with all host railroads and states that own infrastructure over which you operate in an effort to develop and implement 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-19-27) As noted in Amtrak’s submission for this accident, 97 percent of the nearly 21,000 route-miles Amtrak operates are owned by other railroads and subject to host agreements. This reliance on host railroads is a central feature of Amtrak’s business model.55 Host railroad operations are too central to Amtrak’s core business objectives to not be fully accounted for in its safety strategy. Amtrak must envision and then articulate in a written strategy a plan to ensure that risk is managed to a consistent low level across all systems where Amtrak trains operate. Amtrak should denote the specific responsible company positions for managing the safety of trains operating off property. The NTSB concludes this accident again shows that to improve safety for the public, Amtrak needs to implement an SMS on all operations whether internal or on a host railroad. Therefore, the NTSB reiterates Recommendation R-19-27 to Amtrak. The circumstances of this accident show the need for the host railroad(s) to work with Amtrak to develop a comprehensive safety management system program. The NTSB concludes that the application of safety management principles must be uniform across the Amtrak network. Therefore, the NTSB further recommends that all host railroads work in partnership with Amtrak to establish safety management criteria that support the implementation of Amtrak’s SMS.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 6/25/2019
Response: -From Richard Anderson, President and Chief Executive Officer: Amtrak has been working with host railroads and states that own infrastructure over which we operate to implement the Amtrak System Safety Program Plan. We have initiated discussions with hosts and states as part of the implementation process. Amtrak has been working closely with hosts in the area of PTC implementation and the implementation of mitigations as a result of the Non-PTC risk assessments conducted in 2018. As part of this eff01t, Amtrak has met with hosts to review assessments conducted over 1,400 miles of infrastructure that does not have an active PTC system to review risk mitigation proposals. Amtrak will continue to identify opportunities for collaboration. Amtrak will provide updates on the progress of collaboration with hosts and states in the next letter to NTSB.

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.