WASHINGTON (July 27, 2023) — Poor track conditions led to the fatal 2021 Amtrak derailment in Joplin, Montana, the National Transportation Safety Board said Thursday.
NTSB investigators said a combination of factors, including worn rail, vertical track deflection, subgrade instability and track misalignment, led to the derailment of Amtrak’s westbound Empire Builder on Sept. 25, 2021, killing three passengers and injuring 49 passengers and crew. The train, consisting of two locomotives and 10 cars, derailed while in a right-hand curve on BNSF Railway main track.
“This tragedy is a powerful reminder that there’s no substitute for robust track inspection practices, which can prevent derailments by identifying track conditions that may deteriorate over time,” said NTSB Chair Jennifer Homendy. “I implore track owners, who are responsible for the safety of their routes, to ensure inspectors have the time, support, and resources needed to do their work, which is essential to rail safety.”
Worn rail needs to be replaced before the flange of a train wheel contacts the top of a rail joint bar. Excessive wheel flange contact can lead to increased wear and tear on the wheel and rail. Established rail wear limit regulations would have required replacement of the worn rail before wheel flanges contacted a four-bolt joint bar, investigators said.
NTSB investigators also noted 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. BNSF Railway’s lack of management of workloads for safety-related employees indicates a shortcoming in its safety culture.
Contributing to the severity of the injuries was the failure of some windows to stay in place when cars rolled over during the derailment sequence. Performance standards for window retention systems are needed to prevent passenger ejections. Investigators also found that the use of compartmentalization in Amtrak’s passenger railcars did not adequately protect passengers from injury during the derailment.
As a result of this investigation, NTSB issued three new safety recommendations to the Federal Railroad Administration, one to all Class I and intercity railroads and two to BNSF Railway. The recommendations address safety issues including limitations of track inspection practices, autonomous monitoring system and treatment of maintenance rails installed.
NTSB also reiterated recommendations that address retention of passenger windows in railcars and the adequacy of compartmentalization in railcars.
The final report, which includes the findings, probable cause, and all safety recommendations, is available online.
The public docket for the investigation is available online.
To report an incident/accident or if you are a public safety agency, please call 1-844-373-9922 or 202-314-6290 to speak to a Watch Officer at the NTSB Response Operations Center (ROC) in Washington, DC (24/7).
