On September 25, 2021, Amtrak’s Passenger Train 7, the Empire Builder, a passenger train carrying 165 passengers and crewmembers, traveling on track owned and maintained by BNSF Railway, derailed near Joplin, Montana. Three passengers were killed and 49 people were injured. The train consisted of 2 locomotives and 10 railcars. Of the eight passenger railcars that derailed, four derailed on their sides, one derailed leaning, and three derailed upright.
The derailment occurred because of a combination of conditions that affected the BNSF Railway track. These conditions included worn rail, vertical track deflection at a four-bolt rail joint, subgrade instability, and track misalignment. Also, we found that had a locomotive equipped with an existing automated vehicle/track interaction monitoring system traveled the derailment curve on the day of the derailment, the deteriorating track conditions could have been identified and BNSF Railway could have been notified, giving it the opportunity to take action to mitigate the dangers of the misaligned track.
We also found that rail wear limit regulations would have required the worn rail to be replaced before there was wheel flange contact with the four-bolt joint bars. Eight years ago, we recommended that the Federal Railroad Administration revise its Track Safety Standards to require tracks to be repaired if the combination of defects results in a hazardous condition, even if the individual deviations do not constitute a violation.
We also found that walking inspections are important to ensure an understanding of track conditions and that the track inspector’s workload likely prevented him from performing a timely walking inspection of the track in the area of the derailment. We found that BNSF Railway’s lack of management of workloads for safety-related employees indicates a shortcoming in its safety culture, and that a Fatigue Risk Management Program, as required by the FRA, must account for all job responsibilities, duties, and work hours to mitigate the risk of fatigue.
Furthermore, we found that performance standards are needed for window retention systems to prevent passenger ejections. We also found that the approach of compartmentalization in Amtrak’s passenger railcars did not protect the occupants of the overturned railcars from injury during the Joplin derailment.
We determined that the probable cause of the derailment of Amtrak Passenger Train 7 on BNSF Railway track was the combination of worn rail, vertical track deflection at a four-bolt rail joint, subgrade instability, and track misalignment. Contributing to the severity of the injuries were the occupant protections that did not restrain passengers in the overturn event and the failure of the window retention systems.
As a result of this investigation, we recommended that the Federal Railroad Administration require limits for rail head wear, as well as require that the regulations on replacement rail joints be applied to all rail joints in continuously welded rail track without exception. We recommended that the Federal Railroad Administration implement a process where certain alerts from vehicle/track interaction devices automatically trigger a slow order that remains in place until an inspection is completed and the issue is remediated. We recommended that BNSF Railway complete a thorough evaluation of the derailment curve to look for the cause of instability in the subgrade and to make the appropriate repairs once the cause is determined. We also recommended that all Class I and intercity railroad trains operating on main tracks be equipped with a technology-based monitoring system to detect track defects earlier, reducing the likelihood of train derailments.
We reiterated existing recommendations to the Federal Railroad Administration regarding occupant protection and reiterated and gave new classifications to existing recommendations to the Federal Railroad Administration to address combinations of track conditions and the protection of occupants within passenger railcars.