Wednesday, November 15, 2017

NTSB: Amtrak safety culture to blame for fatal crash

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Damage is seen on the front of the Amtrak locomotive that struck a backhoe on April 3, 2016. Damage is seen on the front of the Amtrak locomotive that struck a backhoe on April 3, 2016. National Transportation Safety Board

The National Transportation Safety Board (NTSB) blamed ignored procedures and a fractured safety culture for the April 3, 2016, derailment of Amtrak train 89 near Chester, Penn.

In its report, the NTSB said the accident, which killed a backhoe operator and a track supervisor and left 39 people injured, was caused by "deficient safety management across many levels of Amtrak and the resultant lack of a clear, consistent and accepted vision for safety."

The NTSB said allowing a passenger train to travel at maximum authorized speed on unprotected track where workers were present; the absence of shunting devices, and 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.

The derailment occurred when Train 89 was traveling southbound on the Northeast Corridor from Philadelphia to Washington, D.C., on track 3 and struck a backhoe at about 7:50 a.m. The train’s engineer initiated emergency braking that slowed the train from 106 mph to approximately 99 mph at the time of impact.

The NTSB also noted the Federal Railroad Administration's (FRA) failure to require redundant signal protection, such as shunting, for maintenance-of-way work crews contributed to the incident.

While the NTSB determined that drug use was not a factor, previous reports on the post-accident toxicology tests revealed the backhoe operator tested positive for cocaine, the track supervisor tested positive for codeine and morphine and the locomotive engineer tested positive for marijuana.

The NTSB says that the presence of employees on duty who were unable to pass a drug test highlights another failure to prioritize safety. The U.S. Department of Transportation issued a final rule Nov. 13 that expanded the drug testing panel required of USDOT-regulated employers to include certain semi-synthetic opioids.

"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."

As a result of this investigation, the NTSB issued 14 safety recommendations including nine to Amtrak, two to the FRA and three 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.

"Safety is a core value – for our passengers and our employees – and we are committed to operating our nationwide network of services safely, effectively and efficiently,” Amtrak said in a statement. “We've been in the process of transforming our safety culture since this incident. In the 19 months since the Train 89 event, we have taken a series of actions to improve workplace safety at Amtrak – including the implementation of many of the actions discussed by the NTSB.

"We have a deep sense of obligation to our customers and employees. When a customer buys a ticket from us, or when an employee chooses to come work for us, we have a responsibility to keep them safe. Day in and day out, we work hard to live up to this obligation. We have a team of 20,000 employees who understand that safety is our No. 1 priority, and together we safely operate more than 500 trains across our 21,000-mile network every day."

The railroad also outlined several steps it had taken since the accident and continues to take to improve its safety program.

• Improved communication, such as a weekly safety focus, safety bulletins, safety alerts and rules alerts, which have been incorporated into job briefings and toolbox discussions.

• Revised Roadway Worker Protection (RWP) training, including a comprehensive review and revision of its RWP manual and training programs and clarification of requirements for the use of redundant protection when fouling with equipment.

• Organized the Safety, Compliance and Training resources within a single department, which allows these three functions to work as one team to address safety concerns from multiple angles and in an integrated manner.

• Established a dedicated compliance team to support engineering in the field. Amtrak explains that this team audits Engineering in the field to ensure rules compliance and education.

• Invested in safety leadership with the hiring of Justin Meko as vice president of Safety, Compliance and Training, to lead the new team. Amtrak says Meko is using a disciplined systems approach and best practices to help drive results.

• Redesigned safety training to clarify expectations and require engagement of all employees through a "Safety Starts with Me" initiative. Amtrak notes that safety isn't the sole responsibility of a single department, but is the responsibility of every employee. A redesigned three-day safety training workshop for all operations managers has been implemented and has trained more than 2,000 managers with a plan to extend the training to agreement employees beginning in early 2018.

• Issued a revised and expanded drug and alcohol policy, which was reviewed with employees and managers in November 2016. Amtrak says the drug and alcohol program was expanded to include maintenance-of-way employees in alignment with the FRA final rule 49 CFR 219, which took effect in June 2017. Amtrak also introduced a new Drug and Alcohol Prevention Program in October 2017. Amtrak says the P.I.E.R. program (Prevention, Intervention, Education, Resources) replaces Operation RedBlock and focuses on substance use and abuse prevention.

• Revised its efficiency testing program to focus on activities related to critical rules compliance. Amtrak says the next supervisory/management workshop will be launched this quarter and will focus on providing skills to incorporate best practices in efficiency testing.

• Committed to maintaining an environment where employees are encouraged to report any unsafe condition without fear of retaliation. Amtrak cites its mature Confidential Close Call Reporting (C3RS) programs in place in Transportation and Mechanical and notes that it is evaluating these programs to identify opportunities for expansion throughout the company.

"We have seen the evolution of safety over time at our respective former companies and we know that the journey to get from good to great requires commitment and hard work.” said Amtrak co-CEOs Richard Anderson and Wick Moorman. “At Amtrak, we are on our way, and have taken many important steps in the right direction. We must learn from the past and continue our progress toward becoming the safest passenger railroad. Every one of us must support this effort."

 

READ: Retired Amtrak Engineer warns that Amtrak could be another accident waiting to happen.

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