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On February 4, 2018, southbound Amtrak train 91, operating on a track warrant, diverted from the main track through a hand-thrown switch into a siding and collided head-on with stationary CSX Transportation local freight train F777 03 on the CSX Columbia Subdivision in Cayce, S.C.

The engineer and conductor of the Amtrak train died as a result of the collision and at least 92 passengers and crewmembers on the Amtrak train were transported to medical facilities. The engineer of the stopped CSX train had exited the lead locomotive before the Amtrak train entered the siding, ran to safety, and was not injured. The conductor of the CSX lead locomotive saw the Amtrak train approaching in the siding and ran to the back of locomotive. The conductor was thrown off the locomotive and sustained minor injuries.

The normal method of train operation on the subdivision was a traffic control system with wayside signals. Signal indications authorize movement in either direction. On the day before the accident, CSX signal personnel suspended the traffic control signal system to install updated traffic control system components for implementing positive train control (PTC) on the subdivision. During the suspension, scheduled to last through February 4, 2018, dispatchers would use track warrants to move trains through absolute blocks in the work territory.

National Transportation Safety Board (NTSB) investigators inspected the track structure, signal system and mechanical equipment; collected and are examining records for operations, signal systems, mechanical equipment, and track and engineering; and interviewed train crewmembers, train dispatchers and other personnel from CSX and Amtrak. In addition, investigators are reviewing the emergency response to the accident. Members of the NTSB investigative team traveled to Jacksonville, Fla., to investigate the dispatching aspects of the accident, to test the CSX signal system and to conduct additional interviews.

While on-scene, NTSB investigators located and removed the undamaged event data recorder from the destroyed Amtrak locomotive. The event data recorder was successfully downloaded and an initial review of the data revealed the following information:

  • From the train’s last stop, the maximum speed reached 57 mph, which was below the 59 mph limit allowed under signal suspension rules.
  • About 7 seconds before the end of the recording, the train was moving at 56 mph and the train’s horn was activated for 3 seconds.
  • The brake pipe pressure began decreasing 2 seconds later.
  • The following second, the throttle transitioned from full throttle to idle, while the train was moving at 54 mph.
  • The engineer induced emergency braking one second later, while the train was moving at a speed of 53 mph.
  • The recording ended 2 seconds later, as the train’s air braking system was approaching maximum braking effort and the train’s speed was 50 mph.

The Amtrak locomotive’s forward-facing video recorder hard drive was recovered and downloaded. The initial review of the recording indicated that it ended prior to the collision. NTSB engineers are attempting additional forensic efforts to determine if additional information can be recovered. Other investigative efforts included the download of information from the forward-facing video recorder and the extraction of the event recorder from the CSX lead locomotive.

Parties to the investigation include the Federal Railroad Administration, CSX, Amtrak, Brotherhood of Locomotive Engineers and Trainmen; International Sheet Metal, Air, Rail, and Transportation Workers-Transportation Division; Brotherhood of Railroad Signalmen, and the State of South Carolina Office of Regulatory Staff.

In response to this accident, the NTSB issued an urgent recommendation requesting that the Federal Railroad Administration issue an emergency order providing instructions for railroads to follow when signal suspensions are in effect and a switch has been reported relined for a main track.

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These are the preliminary findings of the NTSB and will be either supplemented or corrected during the course of the investigation.
 

NTSB Figure – A view of the accident scene

The National Transportation Safety Board (NTSB) issued three urgent safety recommendations to the Federal Railroad Administration (FRA), acting upon the agency’s findings in two ongoing railroad accident investigations.

The Federal Railroad Administration (FRA) received one urgent safety recommendation based on NTSB findings in the agency’s investigation of the Feb. 4, 2018, collision of an Amtrak train and a CSX train near Cayce, S.C. The conductor and engineer of the Amtrak train died as a result of the collision. The NTSB issued two urgent safety recommendations to the Metropolitan Transportation Authority (MTA) based on findings from its investigation of the June 10, 2017, Long Island Rail Road (LIRR) accident in which a roadway worker died near Queens Village, N.Y.

In the investigation of the train collision in Cayce, South Carolina, investigators found that on the day before the accident, CSX personnel suspended the traffic control signal system to install updated traffic control system components for the implementation of positive train control (PTC). The lack of signals required dispatchers to use track warrants to move trains through the work territory.

In this accident, and in a similar March 14, 2016, accident in Granger, Wyo., safe movement of the trains, through the signal suspension, depended upon proper switch alignment. That switch alignment relied on error-free manual work, which was not safeguarded by either technology or supervision, creating a single point of failure.

The NTSB concludes additional measures are needed to ensure safe operations during signal suspension and so issued an urgent safety recommendation to the FRA seeking an emergency order directing restricted speed for trains or locomotives passing through signal suspensions when a switch has been reported relined for a main track.

“The installation of the life-saving positive train control technology on the CSX tracks is not the cause of the Cayce, S.C. train collision,” said NTSB Chairman Robert Sumwalt.

“While the collision remains under investigation, we know that signal suspensions are an unusual operating condition, used for signal maintenance, repair and installation, that have the potential to increase the risk of train collisions. That risk was not mitigated in the Cayce collision. Our recommendation, if implemented, works to mitigate that increased risk.” said Sumwalt.

During the investigation of the LIRR accident, the NTSB identified an improper practice by LIRR roadway workers who were working on or near the tracks. LIRR employees were using “train approach warning” as their method of on-track safety, but they did not clear the track, as required, when trains approached and their “predetermined place of safety” did not comply with LIRR rules and procedures.

The NTSB is concerned LIRR management is overlooking and therefore normalizing noncompliance with safety rules and regulations for proper clearing of tracks while using “train approach warning” for worker protection. The two urgent safety recommendations to the MTA call for MTA to audit LIRR’s use of “train approach warning” for worker protection, and, to implement corrective action for deficiencies found through the audit.

The full safety recommendation reports for these urgent safety recommendations are available online at https://goo.gl/z87Dpz and https://goo.gl/LVVef3.

The National Transportation Safety Board (NTSB) determined that two commuter railroad terminal accidents in the New York area were caused by engineer fatigue resulting from undiagnosed severe obstructive sleep apnea.

The Sept. 29, 2016, accident on the New Jersey Transit railroad at Hoboken, New Jersey, killed one person, injured 110, and resulted in major damage to the station. The Jan. 4, 2017, accident on the Long Island Rail Road at the Atlantic Terminal in Brooklyn, New York, injured 108 people. Both accidents involved trains that struck end-of-track bumping posts and crashed into stations.

The NTSB found the two accidents had “almost identical” probable causes and safety issues. The board also determined that these safety issues were not unique to these two properties, but exist throughout the country at many intercity passenger and commuter passenger train terminals.

When operating a train into a terminating track, the engineer’s actions, or lack thereof, solely determine whether the train stops before the end of the track. According to the Federal Railroad Administration (FRA), there are currently no mechanisms installed in the U.S. that will automatically stop a train at the end of the track if the engineer is incapacitated, inattentive or disengaged. Some railroads have overspeed capabilities, including New Jersey Transit and the LIRR. However, as shown in these two accidents, once the engineer slowed the train to the prescribed speed, the system did not stop the trains before they reached the end of the track.

In addition to recommending safety-sensitive personnel be screened for obstructive sleep apnea, the board recommended the use of technology, such as positive train control (PTC), in terminal stations and improving the effectiveness of system safety program plans to improve terminal operations. The NTSB made two recommendations to New Jersey Transit, and the Metropolitan Transportation Authority (the parent company of the Long Island Rail Road) and two to the FRA.

“Today’s new recommendations, if acted upon, have the potential to eliminate end-of-track collisions,’’ Sumwalt said. “That translates to protection for passengers on trains, and for people standing on terminal platforms.”

The complete accident report will be available in several weeks. The findings, probable cause, safety recommendations, Chairman Sumwalt’s prepared remarks and PowerPoint presentations used in a board meeting are all available at https://go.usa.gov/xnscj.

The New Jersey Transit Hoboken accident docket, containing more than 1,100 pages of supporting factual material, is available at https://go.usa.gov/xnAGJ.

The Long Island Rail Road Brooklyn accident docket, containing more than 1,400 pages of supporting factual material, is available at https://go.usa.gov/xnAGe.

 

New Jersey Transit train #1614 after crashing into the NJT Hoboken Terminal, Sept. 29, 2016. (NTSB photo taken by Chris O’Neil)

Sumwalt

Robert Sumwalt, chairman of the National Transportation Safety Board (NTSB), reported some preliminary findings Monday afternoon of his agency’s investigation into the Amtrak-CSX train collision that occurred Feb. 4 near Cayce, S.C.
The train had 139 passengers and eight crewmembers on board. The engineer and conductor in the cab of the locomotive were killed and six passengers remain hospitalized, two in critical condition. SMART TD conductor Michael Cella of Local 30 in Florida was one of two Amtrak crewmembers killed in the accident.
Based upon the event data recorders located within the Amtrak locomotive, Sumwalt said, Amtrak Train 91 was not speeding at the time of the collision.
He said Amtrak’s data recorder had the following information:

  • The train horn was sounded for three seconds at the seven second mark before the collision.
  • The train was traveling at a maximum speed of 57 mph in a 59-mph zone.
  • The engineer moved the throttle to idle and had applied the emergency brakes before the collision.
  • At the time of the collision, the train had reduced its speed to 50 mph.

Sumwalt stated that the reason for the 59-mph speed limit in the area was attributable to track signals being inoperable due to CSX performing upgrades to their track signal system to switch over to positive train control (PTC). He said a track warrant system was in place, and Amtrak had been given clearance to operate in the area.
As previously reported by Sumwalt, a switch had been thrown to allow a CSX train to back into a side track. The switch had never been released back to its original position, and the Amtrak train entered the track where the CSX freight train was parked instead of continuing on the main track.
Sumwalt said that the CSX dispatcher had been notified that the siding operation had been completed and so gave Amtrak clearance to proceed through.
Typically, when the dispatcher is given notification that such a proceeding has been completed, it means that the switch has been moved back into position. The NTSB is investigating as to why the switch had been locked into position for the siding.
Sumwalt reported that interviews with CSX’s engineer, conductor, trainmaster and dispatcher had been conducted Monday along with some of Amtrak’s crew.
Additional interviews are planned for Tuesday. No information about the content of the interviews was released.
The information provided in Monday’s press conference is considered preliminary, and no conclusions should or can be drawn until the NTSB’s investigation is complete and official causes are released by the agency.

A current SMART Transportation Division conductor and a former member were killed when Amtrak Train 91 traveling from New York to Miami collided early Feb. 4 with a stationary CSX freight train east of Columbia, S.C.
Brother Michael Cella, 36, of Orange Park, Fla., was a conductor out of Local 30 in Jacksonville, Fla. He, along with the train’s engineer, Michael Kempf, a former SMART TD member out of Georgia, died in the accident, which injured more than 100 passengers, in Cayce, S.C.
Cella hired on with Amtrak as an assistant conductor in July 2008 and became a full member of SMART TD in September of that year.
The National Transportation Safety Board (NTSB) is investigating the collision that happened about 2:30 a.m. Feb. 4 when the Amtrak locomotive hit the locomotive of the parked CSX train head-on.
Train 91 was carrying eight crew members and 139 passengers, Amtrak said on a posting on its website.
“We are cooperating fully with the NTSB, which is leading the investigation, as well as working with FRA and CSX. CSX owns and controls the Columbia Subdivision where the accident occurred,” Amtrak said in a statement on Twitter. “CSX maintains all of the tracks and signal systems. CSX controls the dispatching of all trains, including directing the signal systems which control the access to sidings and yards.”
NTSB Chairman Robert Sumwalt also said during a news conference that CSX owns and operates the tracks that the Amtrak train was traveling. A switch that was “lined and locked” in the position to divert traffic onto the track where the CSX train was parked is being considered a cause of the accident.
“Key to this investigation is learning why the switch was lined that way,” Sumwalt said.
“We were able to see that it was actually literally locked with a padlock,” he said when asked by a reporter if there was any physical indication that the switch was faulty.
A statement issued by CSX offered condolences to the families of Cella and Kempf and said that the carrier was focused on providing assistance and support to those affected by the accident.
Sumwalt said that the forward-facing video recorder from the Amtrak locomotive had been recovered and was already transported to the NTSB offices in Washington D.C. for investigation.
The event recorders from both trains were still being sought, he said.
“Fully operational positive train control could have avoided this accident,” Sumwalt said.
In a tweet, NTSB said it expected to release additional information at 4 p.m. Eastern Feb. 5.
The Cayce accident is the third fatal incident in three months involving Amtrak trains. A derailment off an overpass in Washington state in December killed three passengers, and an occupant of a garbage truck that was struck by an Amtrak train Jan. 31 near Charlottesville, Va., also died.
Follow this link for video of the NTSB investigation.

WASHINGTON (Jan. 11, 2018) — The National Transportation Safety Board (NTSB) issued four railroad related safety recommendations in concert with the agency’s publication of two railroad accident briefs Thursday, Jan. 11.

The recommendations and briefs stem from the NTSB’s investigations of a railroad employee fatality in Kansas City, Kansas, and a derailment near Heimdal, N.D. The accidents are unrelated.

Recommendation to Union Pacific concerning employee fatality

A Union Pacific Railroad (UP) foreman died after being struck by a remote-control train during switching operations at the east end of Armourdale Yard, Kansas City, Sept. 29, 2015. The NTSB determined the probable cause of the accident was the foreman being in the gage of the track, for unknown reasons, while a train switching movement was being performed by another crew. The report also states inadequate radio communications and inadequate work coordination between crews working in the yard contributed to the accident.

In the course of the investigation the NTSB learned Union Pacific employees received frequent, non-critical, man-down alarms which the NTSB believes likely reduced the attention and reaction crewmembers made to actual critical alarms.

A man-down alarm is an audible warning transmitted of the yard’s radio channels from a remote-control unit (used to remotely control locomotives in the yard) indicating the remote-control unit is not in a vertical position and its operator may be in danger. As a result of the investigation the NTSB issued a safety recommendation to the Union Pacific Railroad to develop and implement a modification to the man-down alarms that would allow workers to differentiate between legitimate and non-critical alarms.

Recommendation to BNSF concerning derailment

A broken wheel led to the derailment of six of the 107 loaded tank cars carrying crude oil in a Burlington Northern Santa Fe crude (BNSF) oil unit train May 6, 2015, near Heimdal, N.D. No injuries or fatalities were reported in connection with the derailment, however five of the derailed tank cars breached, releasing about 96,400 gallons of crude oil. A fire ensued, forcing the evacuation of about 30 people from Heimdal and the surrounding area due to the smoke plume.

The NTSB determined the left wheel, in the second position on car 81 was broken due to a vertical split rim which led to catastrophic failure of the wheel due to multiple overstress fractures.

As a result of the investigation the NTSB issued two safety recommendations to the Federal Railroad Administration (FRA) to research and evaluate wheel impact load thresholds and to mandate remedial actions for railroads to avoid or identify mechanical defects identified by wheel impact load detectors.

A third recommendation was issued to both the FRA and the Association of American Railroads (AAR) seeking collaboration in evaluation of safe peak vertical load thresholds to determine remedial actions for suspected defective wheel conditions in high-hazard flammable train service.

The Heimdal, North Dakota, railroad accident brief is available online at http://go.usa.gov/xndbK and the Kansas City, Kansas, railroad accident brief is available at https://go.usa.gov/xndbN.

Below are the preliminary findings of the National Transportation Safety Board (NTSB) as published on their website.

On December 18, 2017, at 7:33 a.m., Pacific standard time, southbound Amtrak (National Railroad Passenger Corporation) passenger train 501, consisting of a leading and trailing locomotive, a power car, 10 passenger railcars and a luggage car, traveling at 78 mph derailed from a highway overpass near DuPont, Washington.
When the train derailed, it was on its first regular passenger service trip on a single main track (Lakewood subdivision) at milepost (MP) 19.86. The lead locomotive, the power car, and two passenger railcars derailed onto Interstate 5. Fourteen highway vehicles came into contact with the derailed equipment.
At the time of the accident, 77 passengers, 5 Amtrak employees, and a Talgo Incorporated technician were on the train. Of these individuals, 3 passengers were killed, and 62 passengers and crewmembers were injured. Eight individuals in highway vehicles were also injured. The damage is estimated to be more than $40.4 million.
At the time of the accident, the temperature was 48˚F, the wind was from the south at 9 mph, and the visibility was 10 miles in light rain.
The authorized track speed north of the accident site is 79 mph and decreases to 30 mph at MP 19.8, prior to a curve. A 30-mph speed sign, was posted 2 miles before the curve on the engineer’s side of the track, to remind the operating crews of the upcoming speed restriction. Furthermore, another 30-mph speed sign was on the wayside at the beginning of the curve on the engineer’s side of the locomotive.
The lead locomotive’s event data and video recorders were successfully downloaded and processed in the NTSB’s Video Recorder laboratory in Washington, D.C. An initial review of the final portion of the accident sequence revealed the following information:

  • Inward-facing video with audio captured the crew’s actions and their conversations. A forward-facing video with audio captured conditions in front of the locomotive as well as external sounds.
  • The crew was not observed to use any personal electronic devices during the timeframe reviewed.
  • About 6 seconds prior to the derailment, the engineer made a comment regarding an over speed condition.
  • The engineer’s actions were consistent with the application of the locomotive’s brakes just before the recording ended. It did not appear the engineer placed the brake handle in emergency-braking mode.
  • The recording ended as the locomotive was tilting and the crew was bracing for impact.
  • The final recorded speed of the locomotive was 78 mph.

Positive Train Control (PTC), an advanced train control system mandated by Congress in the Rail Safety Improvement Act of 2008, is designed to prevent train-to-train collisions, overspeed derailments, incursions into established work zone limits, and the movement of a train through a switch left in the wrong position. If a train does not slow for an upcoming speed restriction, PTC will alert the engineer to slow the train. If an appropriate action is not taken, PTC will apply the train brakes before it violates the speed restriction. In this accident, PTC would have notified the engineer of train 501 about the speed reduction for the curve; if the engineer did not take appropriate action to control the train’s speed, PTC would have applied the train brakes to maintain compliance with the speed restriction and to stop the train.
Central Puget Sound Regional Transit Authority (Sound Transit) is a public transit agency in the State of Washington. Sound Transit is the owner of the Point Defiance Bypass tracks. The Washington State Department of Transportation (WSDOT) is the owner of the controlling locomotive, and 11 of the 12 passenger cars. WSDOT contracts with Amtrak to operate the train service. As part of that contract with WSDOT, Amtrak provides the train crews and locomotive maintenance. Sound Transit reported that the PTC system on this line was not operational at the time of the accident. The current Federal Railroad Administration (FRA) deadline for PTC implementation is December 31, 2018.
The 55-year-old engineer had been working for Amtrak since May 2004 and had been promoted to engineer in August 2013. The other crewmember in the cab of the locomotive was a 48-year-old “qualifying” conductor who was being familiarized with the territory. This conductor had been working for Amtrak since June 2010 and had been promoted to conductor in November 2011. As of the date of this report, the NTSB has not yet been able to interview either operating crewmember of the lead locomotive due to their injuries sustained in the accident.
The parties to the investigation include the FRA; Amtrak; Sound Transit; State of Washington Utilities and Transportation Commission; Siemens Industry, Incorporated (manufacturer of the locomotive); the Brotherhood of Locomotive Engineers and Trainmen; and the International Association of Sheet Metal, Air, Rail and Transportation Workers.
The information in this report is preliminary and will be either supplemented or corrected during the course of the investigation.

NORTH OLMSTED, Ohio (Dec. 19) — SMART Transportation Division is assisting as the National Transportation Safety Board (NTSB) conducts its investigation and offers its sincere condolences to the victims and families of those affected by the Dec. 18 Amtrak Cascades derailment outside of DuPont, Wash.
Members of SMART TD’s national Safety Task Force have responded to the accident scene and will work along with the NTSB and other rail investigators to help determine probable cause of the accident and to make appropriate safety recommendations at the conclusion of the investigation.
SMART TD has a Party Status agreement with the NTSB that makes the federal agency the chief source of information for this and other accident probes involving trains. Because of this, neither the union nor its representatives will make any official comments as to the status of the accident investigation or the events leading up to the accident. All media inquiries should be directed to the NTSB, which will provide details about the accident and the investigation. Any comment on the investigation from current or former members does not speak for the union or its membership.
“We will await the facts of the investigation and will not speculate in any way about the circumstances leading up to this accident,” SMART TD President John Previsich said. “We offer our sincere condolences to the victims and families of the victims of the Cascades derailment, and our personnel will help investigators as they look for answers as to the cause of this tragedy.”

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The SMART Transportation Division is comprised of approximately 125,000 active and retired members of the former United Transportation Union, who work in a variety of crafts in the transportation industry.

The Amtrak Cascades train 501 that derailed over Interstate 5 near DuPont, Wash., Monday, Dec. 18 was speeding, the National Transportation Safety Board (NTSB) said. The train was traveling at around 80 mph in a 30 mph zone, the agency said.
The train was carrying 80 passengers and five crew members. Three passengers have been reported dead and roughly 100 passengers and motorists were injured. The train had two engines, one at the front and one at the rear, and 12 passenger cars. Thirteen of the 14 cars derailed, with only the rear locomotive staying on the tracks. The derailed cars struck five motor vehicles and two semi-trucks on the highway below.
Click here to read more from Seattlepi.

WASHINGTON (Nov. 14, 2017) — The National Transportation Safety Board (NTSB) determined the April 3, 2016, derailment of Amtrak train 89 near Chester, Pennsylvania, was caused by deficient safety management across many levels of Amtrak and the resultant lack of a clear, consistent and accepted vision for safety.
A backhoe operator and a track supervisor were killed, and 39 people were injured when Amtrak train 89, traveling on the Northeast Corridor from Philadelphia to Washington on track three, struck a backhoe at about 7:50 a.m. The train engineer saw equipment and people working on and near track three and initiated emergency braking that slowed the train from 106 mph to approximately 99 mph at the time of impact.
The NTSB also determined allowing a passenger train to travel at maximum authorized speed on unprotected track where workers were present, the absence of shunting devices, the foreman’s failure to conduct a job briefing at the start of the shift, all coupled with the numerous inconsistent views of safety and safety management throughout Amtrak, led to the accident.
“Amtrak’s safety culture is failing, and is primed to fail again, until and unless Amtrak changes the way it practices safety management,” said NTSB Chairman Robert L. Sumwalt. “Investigators found a labor-management relationship so adversarial that safety programs became contentious at the bargaining table, with the unions ultimately refusing to participate.”
The NTSB also noted the Federal Railroad Administration’s failure to require redundant signal protection, such as shunting, for maintenance-of-way work crews contributed to this accident.
Post-accident toxicology determined that the backhoe operator tested positive for cocaine, and the track supervisor had tested positive for codeine and morphine. The locomotive engineer tested positive for marijuana. The NTSB determined that while drug use was not a factor in this accident, it was symptomatic of a weak safety culture at Amtrak.
As a result of this investigation, the NTSB issued 14 safety recommendations including nine to Amtrak.
The NTSB also made two safety recommendations to the Federal Railroad Administration, and three safety recommendations were issued to the Brotherhood of Maintenance of Way Employees Division, American Railway and Airway Supervisors Association, Brotherhood of Locomotive Engineers and Trainmen and Brotherhood of Railroad Signalmen.
The abstract of the NTSB’s final report, that includes the findings, probable cause and safety recommendations is available online here. The final report will be publicly released in the next several days.
The webcast of the board meeting for this investigation is available for 90 days here.