The National Transportation Safety Board (NTSB) determined November 14 that the April 2016 fatal derailment of a train near Chester, Pennsylvania, was caused by deficient safety management across many levels of the organization and the 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, en route from Philadelphia to Washington, D.C., struck a backhoe. According to NTSB, the train engineer saw equipment and people working on and near the track and initiated emergency braking that slowed the train from 106 miles per hour (mph) to approximately 99 mph at the time of the impact.
“Amtrak’s safety culture is failing, and is primed to fail again, until and unless Amtrak changes the way it practices safety management,” stated NTSB chairman Robert L. Sumwalt. He said investigators found a labor/management relationship so adversarial that safety programs became contentious at the bargaining table, with the unions refusing to participate.
The backhoe operator tested positive for cocaine, the track supervisor tested positive for codeine and morphine, and the locomotive engineer tested positive for marijuana. In this instance, however, NTSB said drug use was not a factor but “was symptomatic of a weak safety culture at Amtrak.”
In the wake of its findings, NTSB issued safety recommendations to Amtrak, to the Federal Railroad Administration, and to the unions representing Amtrak employees. Amtrak says it has a team in place to review the NTSB recommendations and seek to implement them. The railroad pointed to a number of actions already under way to improve workplace safety. Among them Amtrak says it:
- Issued a series of rules alerts and safety advisories in the wake of the incident, in addition to regular weekly safety communications;
- Revised roadway worker protection training that combines professional instruction with scenario-based exercises;
- Reorganized safety, compliance, and training resources into a single department;
- Established a dedicated compliance team to support engineering in the field;
- Invested in safety leadership and launched a “Safety Starts with Me” initiative; and
- Issued a revised, expanded drug and alcohol policy.
Adds Amtrak, “We are committed to maintaining an environment where employees are encouraged to report any unsafe condition without fear of retaliation.”