to provide an effective mitigation for a hazardous curve and inadequate
training of a locomotive engineer led to the overspeed derailment of an Amtrak
passenger train that hurtled off a railroad bridge and onto a busy highway in
DuPont, Washington, the NTSB announced Tuesday.
On the morning of Dec. 18, 2017, Amtrak
Cascades train 501, on its inaugural run on the Point Defiance Bypass between
Seattle and Portland, Oregon, derailed on an overpass as it entered a 30-mph
curve at approximately 78 mph. The lead locomotive and four rail
cars fell onto Interstate 5 where they struck eight vehicles. Three of the 77
train passengers were killed; 57 passengers and crewmembers aboard the train
and eight people on the highway were injured.
“This is the third fatal overspeed
passenger train derailment the NTSB has investigated since 2013,” said NTSB
Chairman Robert L. Sumwalt. “All three have the same thing in common:
each could have been prevented by Positive Train Control. This is why Positive Train
Control is on the NTSB’s 2019-2020 Most Wanted List
of Transportation Safety Improvements. The deadline for full implementation
of PTC is rapidly approaching and the NTSB continues to advocate for the
expedited implementation of this life-saving technology.”
The NTSB said during a public meeting held
Tuesday that the Central Puget Sound Regional Transit Authority failed to
adequately address the hazard associated with a curve that required the train
to slow from 79 mph to 30 mph in order to safely traverse it. Positive
Train Control – a technology that prevents overspeed derailments – was not in
use for the track at the curve.
Ariel view of accident site in DuPont,
Washington (Photo courtesy of Washington State Police)
Although the engineer was somewhat
familiar with the route from observational rides and three training runs, it
was the first time he operated the train on that route in revenue service, and
on a locomotive on which he had very little experience. The NTSB
determined the engineer had insufficient training on both the route and the
Amtrak had equipped the locomotive with an
inward-facing image recorder that provided investigators with both a visual and
audio recording of crewmember activities during the accident trip even though
this device was not required by the Federal Railroad Administration.
This recording allowed investigators to
reconstruct a second-by-second narrative of the actions, movements and words of
the engineer and the conductor throughout the entire trip. The engineer and
conductor engaged in brief conversations throughout the trip; as the train
passed the only sign warning of a speed reduction prior to the accident curve,
the engineer was not engaged in conversation and was looking ahead.
The engineer told investigators that he
did not see the speed reduction sign. Recordings show that he took no action to
reduce the speed of the train prior to the derailment. Investigators
concluded the brief conversations between the engineer and the conductor did
not distract them from their duties or their abilities to identify the speed
Investigators also found the trainset
involved in the crash, which did not meet current crashworthiness standards and
was only permitted to operate through a grandfathering agreement with the
Federal Railroad Administration, was structurally vulnerable to high-energy
derailments or collisions.
Responsibility for the planning, safety
and oversight of the Cascades operation involved numerous organizations,
including Amtrak, the Washington State Department of Transportation, the
Federal Railroad Administration and the Central Puget Sound Regional Transit Authority.
Investigators found there was a general sense that none of the participants
fully understood the scope of their roles and responsibilities as they
pertained to the safe operation of the service, which allowed critical safety
areas to be unaddressed.
As a result of the investigation, the NTSB
issued a total of 26 safety recommendations to the Federal Railroad
Administration, the Washington State Department of Transportation, Oregon
Department of Transportation, Central Puget Sound Regional Transit Authority
and the United States Department of Defense. In addition, the NTSB
reiterated three recommendations to the FRA.
The final report will be available in
several weeks. An abstract of the report that includes findings, probable
cause and safety recommendations is available at https://go.usa.gov/xmwhG.
Additional materials, including Chairman
Sumwalt's opening and closing statements as well as investigator presentations,
are available at https://go.usa.gov/xmwhJ. The
accident docket is
available at https://go.usa.gov/xmvha.