NTSB ON AMTRAK SAFETY PRACTICES: A TRAIN WRECK
FEDS CITE 32 DIFFERENT FACTORS IN PROBE OF FATAL CHESTER CRASH
In this April 2016, file photo, Amtrak investigators inspect a deadly train crash in Chester. The Amtrak train struck a piece of construction equipment, killing two employees on the backhoe.
The National Transportation Safety Board released a scathing report Tuesday naming more than 32 “clumsy Amtrak procedures” that precipitated a train collision that killed two people last year in Chester.
Claiming a bias for productivity over safety, NTSB Chairman Robert Sumwalt said that despite Amtrak’s pledges for safety, that was not the case on the morning of April 3, 2016 when a train full of passengers derailed after and killed two Amtrak maintenance employees.
“Despite the emphasis on rules compliance, investigators did not find a culture of compliance at all,” Sumwalt said. “Rather, they found a culture of fear, on one hand, and normalization of deviance from rules on the other.”
Backhoe operator Joseph Carter Jr., 61, and supervisor Peter Adamovich, 59, were killed and 39 occupants were injured on the train traveling from New York to Savannah, Ga.
Sumwalt called the “systemic.”
“The investigation revealed more than two dozen unsafe conditions, and not all were rulebreaking by front-line employees,” Sumwalt said. “Clumsy Amtrak procedures seemed to encourage work-arounds by workers to ‘get the job done.’”
Citing a failure to use supplemental shunting devices that when used properly will warn dispatchers of workers on an active track, a supervisor who was “disengaged” from critical and regulated problems safety processes, Amtrak’s subpar safety programs and a failure to properly screen workers for drug use, the NTSB said that despite Amtrak’s commitment it failed to “prioritize safety”
“Allowing these unsafe actions to occur were the inconsistent views of safety and safety management throughout Amtrak’s corporate structure that led to the company’s deficient system safety program that resulted in part from Amtrak’s inadequate collaboration with its unions and from its failure to prioritize safety,” the report reads.
Sumwalt suggested that relationships between laborers and management was “so adversarial” that safety programs had become contentious issues at the bargaining table. He said that a fixation on compliance and punishment negated safety principles that precipitated the deaths of the two workers.
Investigators founds that the maintenance crew failed to follow safety procedures, critical safety measures were suspended the night before and never re-established the morning of the accident, safety devices meant to alert a dispatcher of the presence of workers was not installed, and the dispatcher was distracted by a personal call at the time of the incident.
And while NTSB investigators claimed that there was “no operational evidence of impaired performance by the engineer,” the train engineer and two maintenance workers who were killed all tested positive for drug use.
Carter tested positive for cocaine; Adamovich tested positive for morphine, codeine and oxycodone; and the train’s engineer, Alexander Hunter, 47, who has since been fired by Amtrak, tested positive for marijuana.
In the reporter, Hunter was said to have taken “timely and appropriate actions to stop the train and to warn the roadway workers about the train approaching their work area.”
The train was still traveling at 99 mph when it struck the backhoe.
Work on the section on Track 2 at milepost 15.7 had begun April 1, 2016, to clean sections of the track. A foul time is a notification sent to the dispatcher to request that no trains operate on a particular section of track.
Ryan Frigo, the lead NTSB investigator, said the night foreman on the evening of April 2 released the foul time of Tracks 1, 3, and 4. Frigo said the day foreman did not make the call to reestablish the foul times on the morning of April 3.
“Because the tracks were reported clear, the dispatcher was authorized to use them,” Frigo said.
“Had the two foreman communicated with the train dispatcher jointly about the transfer of fouls from one foreman to the other, it is likely that on-track safety and protection would not have lapsed and the accident would not have happened,” the report reads.
Additionally, Frigo said the dispatcher was on a personal call and not monitoring traffic on his display board when the collision occurred.
“The personal phone calls made by the day train dispatcher while he was on duty distracted him from performing his job,” the report claims.
As a result of the report, Amtrak has been issued new recommendations for safety that include precautions that active work zone protection is not lost between shift transfers, require supervisors to log foul times, avoid dispatcher distractions and make sure employees do not suffer reprisal from management for following safety precautions.
“In the wake of an accident, an ineffective safety culture can be more elusive to identify than the individual errors that are its symptoms,” Sumwalt said. “But, as difficult as it might be for Amtrak to change its safety culture, the potential safety benefit to Amtrak’s employees and riders cannot be overstated.”
Officials at the location of the fatal Amtrak accident in Chester on April 3, 2016.