NTSB: Inadequate planning, training caused Amtrak 501 wreck

Written by Andrew Corselli

Failure to provide an effective mitigation method for a hazardous curve and inadequate training of a locomotive engineer is what led to the derailment of an Amtrak passenger train that hurtled off a railroad bridge and onto a busy highway in DuPont, Wash., on the morning of Dec. 18, 2017, according to the National Transportation Safety Board (NTSB).

On that day, Amtrak Cascades train 501, on its inaugural run on the Point Defiance Bypass between Seattle, Wash., and Portland, Ore., derailed on an overpass as it entered a 30-mph curve at approximately 78 mph. The lead locomotive and four rail cars fell onto Interstate 5 where they struck eight vehicles. Three of the 77 train passengers were killed, and 57 passengers and crewmembers aboard the train and eight people on the highway were injured.

The NTSB said during a public meeting held May 21 that the Central Puget Sound Regional Transit Authority failed to adequately address the hazard associated with a curve that required the train to slow from 79 mph to 30 mph in order to safely traverse it. Positive Train Control was not in use for the track at the curve.

In addition, the engineer was somewhat familiar with the route from observational rides and three training runs, but the accident was the first time he operated the train on that route in revenue service. So the NTSB determined the engineer had insufficient training on both the route and the equipment.

Furthermore, Amtrak had equipped—though it wasn’t required to by the Federal Railroad Administration (FRA)—the locomotive with an inward-facing image recorder that provided investigators with both a visual and audio recording of crewmember activities during the accident.

The recording allowed investigators to reconstruct a second-by-second account of the conductor and engineer’s actions and words throughout the entire trip. According to the NTSB, the pair engaged in brief conversations throughout the trip; as the train passed the only sign warning of a speed reduction prior to the accident curve, the engineer was not engaged in conversation and was looking ahead.

The engineer told investigators that he did not see the speed reduction sign. Recordings show that he took no action to reduce speed prior to the derailment. Investigators concluded the brief conversations between the engineer and the conductor did not distract them from their duties or their abilities to identify the speed reduction sign.

Investigators also found the trainset involved in the crash, which did not meet current crashworthiness standards and was only permitted to operate through a grandfathering agreement with the FRA, was structurally vulnerable to high-energy derailments or collisions.

Responsibility for the planning, safety and oversight of the Cascades involved numerous organizations, such as Amtrak, the Washington State Department of Transportation, the FRA and the Central Puget Sound Regional Transit Authority. Investigators found there was a general sense that none of the participants fully understood the scope of their roles and responsibilities as they pertained to the safe operation of the service, which allowed critical safety areas to be unaddressed.

On the heels of the investigation, the NTSB issued a total of 26 safety recommendations to the FRA, the Washington State Department of Transportation, Oregon Department of Transportation, Central Puget Sound Regional Transit Authority and the United States Department of Defense.  In addition, the NTSB reiterated three recommendations to the FRA.

“This is the third fatal overspeed passenger train derailment the NTSB has investigated since 2013,” said NTSB Chairman Robert L. Sumwalt. “All three have the same thing in common: each could have been prevented by Positive Train Control. This is why Positive Train Control is on the NTSB’s 2019-2020 Most Wanted List of Transportation Safety Improvements. The deadline for full implementation of PTC is rapidly approaching and the NTSB continues to advocate for the expedited implementation of this life-saving technology.”

The final report will be available “in several weeks,” according to the NTSB. An abstract report can be found here, an event summary can be viewed here and the accident docket can be seen here.

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