NTSB: Am­trak’s lax safety cul­ture led to deadly crash

The Citizens' Voice - - Local - BY MICHAEL R. SISAK

PHILADEL­PHIA — Fed­eral in­ves­ti­ga­tors said Tues­day they found ma­jor lapses in how Am­trak deals with safety, in­clud­ing more than two dozen haz­ardous con­di­tions at the work zone near Philadel­phia where a train slammed into a main­te­nance back­hoe last year and killed two work­ers.

Chief among them, in­ves­ti­ga­tors said, were a fore­man’s fail­ure to make sure dis­patch­ers were still rerout­ing trains from the area un­der re­pair near Philadel­phia and the crew’s fail­ure to use a de­vice that would have au­to­mat­i­cally blocked trains from ac­cess­ing those tracks.

“Had any of these is­sues been ad­dressed, the ac­ci­dent may have been pre­vented,” Na­tional Trans­porta­tion Safety Board in­ves­ti­ga­tor Joe Gor­don said at a pub­lic meet­ing on the crash at the agency’s Wash­ing­ton head­quar­ters.

The April 2016 crash killed back­hoe op­er­a­tor Joseph Carter Jr. and su­per­vi­sor Peter Adamovich. About 40 pas­sen­gers on the New York to Sa­van­nah, Georgia, train were in­jured.

Am­trak work­ers told in­ves­ti­ga­tors that the gov­ern­ment-owned rail­road em­pha­sized on-time per­for­mance over safety, yet plas­tered em­ployee lounges with big, red signs re­mind­ing them to “think safety” and threat­ened to fire work­ers who broke cer­tain rules.

NTSB chair­man Robert Sumwalt said Am­trak’s grab bag of pri­or­i­ties cre­ated a cul­ture of fear and non­com­pli­ance where bend­ing the rules seemed ac­cept­able to “get the job done.”

“Am­trak’s lack of a strong safety cul­ture is at the heart of this ac­ci­dent,” in­ves­ti­ga­tor Mike Hoepf said.

Am­trak’s co-chief ex­ec­u­tive of­fi­cers, Richard An­der­son and Charles “Wick” Moor­man sent a let­ter to em­ploy­ees Tues­day up­dat­ing them on steps the rail­road has taken to trans­form its safety cul­ture since the crash.

They in­clude hir­ing a new head of safety, com­pli­ance and train­ing, is­su­ing alerts and ad­vi­sories to re­mind work­ers of rules and an im­proved work­er­pro­tec­tion train­ing pro­gram.

“Our cus­tomers ex­pect us to op­er­ate safely and our jobs and lives de­pend on it,” the co-CEOs wrote. “We can and will do bet­ter. Our pledge to you is that we will do ev­ery­thing pos­si­ble to help move us for­ward.”

Carter’s fam­ily is su­ing Am­trak for neg­li­gence. Their lawyer, Tom Kline, said they can only hope his death “will re­sult in whole­sale changes” in safety at Am­trak.

Tox­i­col­ogy re­ports showed that Carter, 61, had co­caine in his sys­tem, Adamovich, 59, tested pos­i­tive for mor­phine, codeine and oxy­codone and the train’s en­gi­neer, Alexan­der Hunter, 47, tested pos­i­tive for mar­i­juana.

Only Hunter, as a train crew mem­ber, would have been sub­ject to ran­dom drug test­ing at the time of the crash. In June, fed­eral reg­u­la­tors ex­panded the test­ing pro­gram to in­clude track main­te­nance work­ers. On Mon­day, the Fed­eral Rail­road Ad­min­is­tra­tion is­sued a rule man­dat­ing test­ing for opi­oids be­gin­ning Jan. 1.

Hunter is no longer em­ployed by Am­trak. No amount of mar­i­juana use by an en­gi­neer is ac­cept­able, the rail­road has said.

He told in­ves­ti­ga­tors that he knew of main­te­nance work be­ing done in the area but was not given any warn­ings about equip­ment be­ing on the same track as his train.

Hunter blew the train’s horn and hit the brakes once he saw equip­ment on an ad­ja­cent track and then on his own track. In­ves­ti­ga­tors say that was about 12 sec­onds be­fore im­pact.

The train slowed from 106 mph to 100 mph at im­pact and only came to a com­plete stop about a mile down the track. The lead en­gine of the train de­railed.


Am­trak in­ves­ti­ga­tors in­spect the deadly train crash in Ch­ester in April 2016. The crash killed back­hoe op­er­a­tor Joseph Carter Jr. and su­per­vi­sor Peter Adamovich, and about 40 pas­sen­gers were in­jured.

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