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Safety Recommendation Details

Safety Recommendation R-19-032
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 CENTRAL PUGET SOUND REGIONAL TRANSIT AUTHORITY: Review your internal process for safety certification and verification, perform a gap analysis, and develop an action plan to address the deficiencies identified in the gap analysis and detailed in this report to enhance the verification activities on projects.
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: Central Puget Sound Regional Transit Authority (Open - Await Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Central Puget Sound Regional Transit Authority
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, 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 Central Puget Sound Regional Transit Authority. Additional information regarding these recommendations can be found in the noted sections of the report. • Immediately conduct a review of all operating documents and ensure that safety mitigations are applied with uniformity throughout the entirety of your territory. (R-19-030) (See section 2.5.3.) • In areas of your territory where you are a host of a tenant railroad, coordinate with all current and any prospective tenants on the development of operating documents including timetables, general orders, and special instructions. (R-19-031) (See section 2.5.3.) • Review your internal process for safety certification and verification, perform a gap analysis, and develop an action plan to address the deficiencies identified in the gap analysis and detailed in this report to enhance the verification activities on projects. (R-19-032) (See section 2.5.6.) 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-19-030). 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.