Here is the brief NTSB released one month
before this derailment on the 2016 accident.
As usually they are incredible ( reason why there was no deaths last year aviation wise) is them !!
WOuld be so cool if the rest of our govt operated the way they have decades
There is no 10 percent stuff - its public record!
There final reports ( before internet they were called blue cover -- means final!)are incredible -- hundreds of pages
They were free you asked for them they mailed them to you !!
Have no idea to this day how I knew to write them for them but I started at like 13 and would be so excited when my manilla envelope came.
Now there all on line !
This will give you an idea of their writirng style
THey hold huge public hearings - before writing the final. Usually take about 18 months for each one
the do aviation rail marine pipeline accidents
they have no power to enforce- there mandate is to make reccs to the FAA who ignore them until there is a big event .
Then FAA takes another 4 or so years BSing around!
Aviation has been their forte -- when Delta 191 hearings were held I asked for me going out there to be my birthday gift/
I thought it was a totally fine birthday request!! My father thought I was nutsola/
I have proven that to be true as years have passed!!
I went over to all the challenger hearings - they were amazing~
TIONAL TRANSPORTATION SAFETY BOARDPublic Meeting of November 14, 2017(Information subject to editing)Amtrak Train Collision withMaintenance-of-Way EquipmentChester, PennsylvaniaApril 3, 2016NTSB/RAR-17/02This is a synopsis from the NTSB’s report and does not include the Board’s rationale for theconclusions, probable cause, and safety recommendations. NTSB staff is currently making finalrevisions to the report from which the attached conclusions and safety recommendations have beenextracted. The final report and pertinent safety recommendation letters will be distributed torecommendation recipients as soon as possible. The attached information is subject to furtherreview and editing to reflect changes adopted during the Board meeting.Executive SummaryOn April 3, 2016, about 7:50 a.m. eastern daylight time, southbound Amtrak train 89 (train89) struck a backhoe with a worker inside at milepost 15.7 near Chester, Pennsylvania. The trainwas authorized to operate on main track 3 (track 3) at the maximum authorized speed of 110 mph.Beginning on the morning of April 1, Amtrak had scheduled track-bed restoration―ballastvacuuming—at milepost 15.7 on track 2 on the Philadelphia to Washington Line. Track 2 had tobe taken out of service between control points Baldwin (milepost 11.7) and Hook (milepost 16.8)for the 55 hour duration of the project. As train 89 approached milepost 15.7, the locomotiveengineer saw equipment and workers on and near track 3 and initiated an emergency brakeapplication. The train speed was 106 mph before the emergency brake application and 99 mphwhen it struck the backhoe. Two roadway workers were killed, and 39 other people were injured.Amtrak estimated property damages to be $2.5 million.The accident investigation focused on the following safety issues:• Roadway Worker Protection: Amtrak and the North American Operating RulesAdvisory Committee have many rules for ways to protecting workers on maintenanceof way projects. These include positive train control, which is designed, in part, toprevent incursions into work zones; using Form D and foul time to prevent trainincursions into the work zone; supplemental shunting devices that activate trackoccupancy detection within the signal system and create a track occupancy light on thedispatcher’s board, thus serving as an independent layer of safety; site-specific workplans that assess the risk of worksites to guide choices like the number of watchmenneeded; and a job briefing conducted before each shift that includes the type of workerprotection to be used.• Communication Between Dispatchers and Foremen: This accident included severalactions by dispatchers and foremen that affected the performance of their jobs andultimately the safety of the work on the day of the accident. Most of thecommunications were made over cell phones instead of the radio. Because of this, noone else at Amtrak was able to hear the content of the conversations. Another listenermay have been able to identify errors or incorrect decisions or assumptions made duringthese conversations.• Lack of Job Briefing: The day foreman did not conduct a job briefing for the roadwayworkers and contractors before the shift began. A job briefing is required and includesthe form(s) of protection from intrusions onto out of service tracks that will be usedduring the upcoming shift. The track protection information included in the job briefingmakes workers aware of the presence or absence of track protection and enables themto question the absence of that protection if the protection plan has not been followed.• Safety Management: The Chester accident investigation revealed 20 active failures ofmore than 2 dozen unsafe conditions—many involving safety rule violations and riskybehaviors by workers. These safety shortcomings occurred across several levels of theAmtrak organization—maintenance of way, dispatchers, management—and revealAmtrak’s weak safety management. An inconsistent vision of safety throughout theorganization, hostile attitudes between labor and management about no-tolerance ruleviolations, and ill-equipped work crews were among the observed safety culture.Moreover, it is disconcerting that three of the Amtrak employees involved in theaccident tested positive for potentially impairing drugs. at more than one level ofmanagement. The company’s safety program and its implementation at all levels of thecompany were found to be weak and focused on only the lowest level of employees:the roadway workers.Findings1. The track structure, signals, and mechanical equipment did not contribute to the accident.2. The track supervisor had used two different opioids at some point before the accident, butbased on behavioral evidence, drug-induced impairment of his job performance could notbe determined.3. The Amtrak engineer took timely and appropriate actions to stop the train and to warn theroadway workers about the train approaching their work area.4. Although there was no operational evidence of impaired performance by the engineer, hisuse of marijuana was illicit and had not been deterred by his participation in the USDepartment of Transportation drug testing program, and any previous marijuana use hadnot been detected by random drug testing.5. Amtrak did not effectively assure that its employees, especially those in safety-sensitivepositions, were drug-free while performing their public transportation duties.6. Had the two roadway workers used cocaine, codeine, or morphine with some regularity,been subject to random urine drug screening, and been selected for testing, their use ofcocaine and opiates may have been detected before the accident.7. The absence of a random drug testing program for maintenance-of-way employees at thetime of the accident meant there was no effective program to deter the maintenance of wayemployees from using drugs.8. The participation of the two roadway workers in the pool for random testing might havedeterred them from using cocaine and opiates.9. The result of the night foreman’s actions and the day foreman’s inactions based on theirconversation was that tracks 1, 3, and 4 were not protected with foul time from about 7:30a.m. until 7:50 a.m. when the accident occurred.10. Had the two foremen communicated with the train dispatcher jointly about the transfer offouls from one foreman to the other, it is likely that on-track safety and protection wouldnot have lapsed and the accident would not have happened.11. The inadequate and inconsistent use of supplemental shunting devices by Amtrakengineering personnel effectively defeated the roadway worker protection component ofAmtrak’s Advanced Civil Speed Enforcement System and thereby placedmaintenance-of-way employees, equipment, and the traveling public at greater risk ofharm.12. Had the foremen ensured supplemental shunting devices were in place, the accident wouldnot have occurred.13. There was wide acceptance at Amtrak of not using supplemental shunting devices.14. A specific efficiency test code for the foul time process that assesses supplemental shuntingdevice use would give Amtrak the ability to monitor and improve supplemental shuntingdevice compliance and change the culture of noncompliance.15. Had the Federal Railroad Administration required shunting as recommended by theNational Transportation Safety Board in Safety Recommendation R-08-06, the accidentwould not have occurred.16. Amtrak management should have recognized that the project rose to a heightened level ofhazard that required a detailed review or site-specific work plan before it began.17. Safety hazards exist at complex smaller projects, and these hazards should be assessed andaddressed with site-specific work plans.18. Disengagement by a supervisor from a critical and regulated safety communication processreduces safety layering and at a minimum encourages other lax safety habits.19. Had the supervisor been engaged with his duties and responsibilities, a proper and thoroughjob briefing would likely have been conducted and the employees would have had anopportunity to ask the day foreman how on-track safety was to be provided.20. Had the day foreman conducted a thorough job briefing for all workers on the day shift,including the supervisor, before the work began, foul time protection or the lack thereofand which foreman had the foul time likely would have been discussed and then rectifiedor mitigated by removal of the backhoe from track 3.21. Each employee present at the work site had the obligation to demand that a proper jobbriefing be conducted before they signed the safety briefing sheet.22. The supervisory oversight in Amtrak’s dispatcher center did not adequately monitordispatcher responsibilities to ensure that supplemental shunting devices were used.23. The personal phone calls made by the day train dispatcher while he was on duty distractedhim from performing his job.24. Amtrak’s ongoing infrastructure work creates an increased exposure of roadway workersto incidents like the one at Chester.25. Had Amtrak instructed dispatchers to operate trains at significantly slower speeds throughthe Chester work zone, the severity of the accident would have been diminished.26. Amtrak’s rules and supervisor expectations for dispatchers did not adequately emphasizesafety.27. These 29 active failures and latent conditions indicate a systemic problem with Amtrak’ssafety culture.28. Amtrak’s safety programs were deficient and failed to provide effective first-line safetyoversight.29. Amtrak did not have a viable reporting system in place to collect safety critical information.30. The lack of consistent knowledge and vision for safety across Amtrak’s managementcreated a culture that facilitated and enabled unsafe work practices by employees.31. Amtrak did not have an effective safety management system program.32. By delaying progressive system safety regulation, the Federal Railroad Administration hasfailed to maximize safety for the passenger rail industry and the traveling public.PROBABLE CAUSEThe National Transportation Safety Board determines that the probable cause of theaccident was the unprotected fouled track that was used to route a passenger train at maximumauthorized speed; the absence of supplemental shunting devices, which Amtrak required but theforeman could not apply because he had none; and the inadequate transfer of job siteresponsibilities between foremen during the shift change that resulted in failure to clear the track,to transfer foul time, and to conduct a job briefing. Allowing these unsafe actions to occur werethe inconsistent views of safety and safety management throughout Amtrak’s corporate structurethat led to the company’s deficient system safety program that resulted in part from Amtrak’sinadequate collaboration with its unions and from its failure to prioritize safety. Also contributingto the accident was the Federal Railroad Administration’s failure to require redundant signalprotection, such as shunting, for maintenance-of-way work crews who depend on the traindispatcher to provide signal protection, prior to the accident.RECOMMENDATIONSNew RecommendationsAs a result of this investigation, the National Transportation Safety Board makes safetyrecommendations to the Federal Railroad Administration, Amtrak, Brotherhood of Maintenanceof Way Employes Division, American Railway and Airway Supervisors Association, Brotherhoodof Locomotive Engineers and Trainmen, and Brotherhood of Railroad Signalmen. The NationalTransportation Safety Board also reiterates a recommendation to the Federal RailroadAdministration.To the Federal Railroad Administration:1. Enact Title 49 Code of Federal Regulations Part 270, System Safety Program,without further delay.2. Require railroads to install technology on hi-rail, backhoes, otherindependently operating pieces of maintenance-of-way equipment and on theleading and trailing units of sets of maintenance-of-way equipment operatedby maintenance workers to provide dispatchers and the dispatch system anindependent source of information on the locations of this equipment toprevent unauthorized incursions by trains onto sections of track wheremaintenance activities are taking place in accordance with the Congressionalmandate under the Rail Safety Improvement Act of 2008. To Amtrak:3. Establish a method to ensure that on-track protection in an active work zoneis not lost during shift transfer.4. Develop and implement an engineering safety procedure for preparingsite-specific work plans for maintenance projects on the Northeast Corridormain line tracks spanning multiple shifts or multiple workdays to reduce ormitigate the inherent risks of maintenance-of-way work in a high-speed trainoperations environment.5. Require supervisors to review train dispatchers’ foul time log sheets to verifywhether supplemental shunting devices are being adequately applied.6. Revise its train dispatcher rules so that potentially distracting activities, suchas making personal telephone calls, are not allowed while dispatchers are onduty and responsible for safe train operations.7. Conduct a risk assessment for all engineering projects; use the results to issuesignificant speed restrictions for trains passing any engineering project thatinvolves safety risks for workers, equipment, or the traveling public, such asballast vacuuming, as part of a risk-mitigation policy.8. Work with labor to achieve full participation in all applicable safetyprograms.9. Work collaboratively with labor to develop and implement a viable safetyreporting system (for example, C3RS); ensure that employees do notexperience reprisal for using the system; respond quickly on the datacollected; and communicate any resulting safety improvements to allemployees.10. Work collaboratively with labor in an effort to develop a comprehensivesafety management system program that complies with pending FederalRailroad Administration regulation Title 49 Code of Federal RegulationsPart 270, System Safety Program, and that vitalizes safety goals andprograms with executive management accountability; incorporates riskmanagement controls for all operations affecting employees, contractors, andthe traveling public; improves continually through safety data monitoringand feedback; and is promoted at all levels of the company.11. Once [the previous safety recommendation] is completed, implement thesafety management system program throughout the company with resourcessufficient to ensure that all levels of management and all labor unionsinvolved with Amtrak operations accept and comply with the system.To Brotherhood of Maintenance of Way Employes Division, AmericanRailway and Airway Supervisors Association, Brotherhood of LocomotiveEngineers and Trainmen, and Brotherhood of Railroad Signalmen:12. Work with Amtrak to improve the effectiveness of all applicable safetyprograms.13. Work collaboratively with Amtrak to develop and implement a viable safetyreporting system (for example, C3RS).14. Work collaboratively with Amtrak in an effort to develop a comprehensivesafety management system program that complies with pending FederalRailroad Administration regulation Title 49 Code of Federal RegulationsPart 270, System Safety Program, and that vitalizes safety goals andprograms with executive management accountability; incorporates riskmanagement controls for all operations affecting employees, contractors, andthe traveling public; improves continually through safety data monitoringand feedback; and is promoted at all levels of the company.Previously Issued Recommendation Reiterated in This ReportTo the Federal Railroad Administration:Require redundant signal protection, such as shunting, for maintenance-of-waywork crews who depend on the train dispatcher to provide signal protection.
