Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation R-19-037
Details
Synopsis: On February 4, 2018, about 2:27 a.m., southbound Amtrak (National Railroad Passenger Corporation) train P91, operating on a track warrant, was diverted from the main track through a reversed hand-throw switch into a track and collided head-on with a stationary CSX Transportation Corporation (CSX) local freight train F777. The accident occurred on CSX’s Florence Division, Columbia Subdivision in Cayce, South Carolina. The engineer and conductor of the Amtrak train died because of the collision. Ninety-one passengers and crew members on the Amtrak train were transported to medical facilities. The engineer of the stopped CSX train had exited the lead locomotive before the Amtrak train entered the track, ran to safety, and was not injured. The conductor on the CSX lead locomotive saw the Amtrak train approaching on the track and ran to the back of locomotive. The conductor was thrown off the locomotive and sustained minor injuries. Damage was estimated at $25.4 million. The investigation focused on the following safety issues: the medical examination process for railroad employees, the actions and responsibilities of the train crew handling the switches, operations during signal suspensions, a CSX efficiency testing program, implementation of a safety management system by Amtrak, and occupant protection in passenger railcars. As a result of the investigation, the National Transportation Safety Board makes two safety recommendations to CSX and one safety recommendation to all host railroads. The National Transportation Safety Board also reiterates four recommendations to the Federal Railroad Administration and one recommendation to Amtrak. Further, the NTSB reclassifies two recommendations to the Federal Railroad Administration.
Recommendation: TO CSX TRANSPORTATION CORPORATION: Develop and implement a safety management system that includes but is not limited to operations, training, maintenance, equipment, and medical standards.
Original recommendation transmittal letter: PDF
Overall Status: Open - Await Response
Mode: Railroad
Location: Cayce, SC, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: RRD18MR003
Accident Reports: Safety Recommendation Report: Train Operation During Signal Suspension​Preliminary Report Railroad: Head-on Collision Between Amtrak Passenger Train and CSX Freight Train RRD18MR003​Amtrak Passenger Train Head-on Collision With Stationary CSX Freight Train
Report #: RAR-19-02
Accident Date: 2/4/2018
Issue Date: 9/30/2019
Date Closed:
Addressee(s) and Addressee Status: CSX Transportation, Inc. (Open - Await Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: CSX Transportation, Inc.
Date: 9/30/2019
Response: 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-19-36). 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 CSX Transportation (CSX) 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 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 efficiency testing program and staffing. ??Operations during signal suspensions. • Implementation of a safety management system by Amtrak (National Railroad Passenger Corporation) to assess and mitigate risks for operation on host railroads. • Occupant protection in passenger railcars. Accordingly, the NTSB makes the following safety recommendations to CSX. Additional information regarding these recommendations can be found in the noted sections of the report. • Develop a device or technique to eliminate the possibility of employees failing to perform critical tasks such as lining a switch, lining a derail, or ensuring cars are clear of the main track. (R-19-36) (See section 2.5.) • Develop and implement a safety management system that includes but is not limited to operations, training, maintenance, equipment, and medical standards. (R-19-37) (See section 2.7.) In addition, the NTSB makes the following recommendation to all of the host railroads, including CSX: • Work in partnership with Amtrak (National Railroad Passenger Corporation) to establish safety management criteria that support the implementation of Amtrak’s safety management system. (R-19-38) (See section 2.6.4.) 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 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-19-36). 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.