Daily Times (Primos, PA) - - FRONT PAGE - By Rick Kauff­man rkauff­man@21st-cen­tu­ry­media.com @Kauf­fee_DT on Twit­ter

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.

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