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National Transportation Safety Board releases findings on deadly 2017 Amtrak crash

“Three people did not have to die”

Courtesy of WSDOT

At about 7:34 a.m. on December 18, 2017, tragedy struck in DuPont near Joint Base Lewis-McChord: An Amtrak train on the Cascades line derailed, moving about 80 miles per hour, taking a turn on the first day of a brand-new route. Three people were killed in the crash and 57 passengers were injured as 13 out of 14 cars derailed, including one locomotive. Eight more were injured from cars falling onto Interstate 5.

The three passengers who lost their lives in the crash were friends and rail advocates Zack Willhoite and Jim Hamre, 35 and 61, and Benjamin Gran, 40, of Auburn. All three were train enthusiasts excited to take the inaugural voyage on the new line.

The National Transportation Safety Board (NTSB), an independent, federal investigative committee, arrived at the scene quickly, and while investigators released some initial insight, the agency said full results wouldn’t be available for a year or two.

Tuesday, NTSB released more detailed findings: The crash, said chair Robert Sumwalt, was preventable. The speed limits didn’t come with “appropriate mitigations,” said Sumwalt, and service should not have began without certain safety measures in place. Sumwalt also noted there were “training gaps” for operators. Investigators also found gaps in oversight from WSDOT, Sound Transit, Amtrak, and the Federal Railroad Administration (FRA).

Not a unique problem

Sumwalt, in his opening remarks, pointed to similar derailments related to speed limit decreases going into sharp curves, including a 2013 Metro North train in the Bronx and a 2015 Amtrak train near Philadelphia,

“There is certainly a recent history of this type of accident,” said Sumwalt, “and it extends back decades as well.”

All these accidents, said Sumwalt, “failed to respond to significant speed changes. And reasons for this vary, but there is one common denominator: Necessary decreases in speed limits going into sharp curves with insufficient mitigation.”

Safety equipment not installed

Both the route and the equipment were new to the Cascades, including the high-speed locomotives pulling the train. The trains, and the tracks they were running on, included equipment designed to stop the train in the event of a hazard, but the system controlling that equipment—positive train control, or PTC—was still in testing and wasn’t scheduled to be activated until the next year. (It has since been installed.)

Lack of PTC was a large theme in the findings. In 2015, Sound Transit identified derailment risk of the curve where the crash occurred, the Point Defiance Bypass. Mitigations at the time included speed limits up to federal standards, new inspection and maintenance procedures, and PTC.

“Beginning revenue service before PTC was operational it set up the engineer to fail,” said Sumwalt.

“The hazard associated with derailments and curves was overlooked throughout the process, and the mitigation was erroneously classified as ‘completed, accepted,’” said NTSB investigator Ryan Frigo, addressing the board. “Ideally, Sound Transit could have waited until PTC was completely installed and operational before allowing passenger service on the point defiance bypass.”

So what was the holdup?

“There basically were three entities [responsible for] getting it fully deployed,” said investigator Timothy DePaepe to the board. Amtrak was responsible for train equipment. Sound Transit was responsible for having equipment and software “out in the field.” Burlington Northern Santa Fe was responsible for “back office” stuff like software and dispatch.

“While some of all three parts were done, the back office software was not complete, so there had been no testing yet,” said DePaepe.

Training and documentation

The engineer charged with the train, said Sumwalt, was an experienced operator. He was nervous about the curve, and had paid for a hotel room in Seattle the night before at his own expense to get a good night’s rest. The investigation found that he was healthy, wasn’t under the influence of drugs or alcohol, and he wasn’t distracted by a cell phone or radio communication. Both the engineer and the conductor were attentive, the investigation found.

Neither of the operators, however, were familiar with the trip. The engineer had only made one southbound trip before out of three total practice trips on the new route. The conductor was still in training on the route, with the understanding of taking a more passive role. And, according to investigators, neither of them had been trained in all of the train’s systems—including the overspeed alarm, which kicked in shortly before the accident as the train ticked three miles per hour above the general speed limit.

“The engineer had never experienced this alarm while operating the new charger locomotive, and did not immediately recognize what was being presented on the two screens,” explained investigator Stephen Jenner. “In fact, inward facing video shows that he was scanning both screens for about 20 seconds, trying to assess the situation. During this period, however, he rarely looked outside the train, which had now traveled another half mile and was nearing the curve. The engineer finally did understand the alarm, but only seconds later he recognized where he was and it was too late to avoid the derailment.”

“He appeared confused,” said Jenner. “He needed time to evaluate the information, but that reduced his vigilance outside the train.”

The engineer, according to Jenner, had also missed a sign warning of the upcoming speed limit—which had been placed at a location more relevant to freight trains than passenger trains.

Additionally, neither WSDOT or Sound Transit’s operating documents were up to date, and neglected to include the stretch where the accident occurred as a “crew focus zone,” which requires additional vigilance and communication between the engineer and conductor, with a failsafe requiring the conductor to stop the train if there’s no response from the engineer.

According to Frigo, Sound Transit had intended to name the area a crew focus zone the month after the derailment. The zone was eventually implemented and is now in place.

Exemptions from safety standards

The train configuration, simply put, was not up to date—although it had federal approval. When the FRA updated safety standards in 1999, Amtrak petitioned for an exception, which was granted in 2000, provided some additional safety measures were in place, including adding safety cables between cars and in the rolling assembly underneath.

This train, a Talgo 6 configuration, was operating under exemption. Meanwhile, the mandated cables were showing wear. The NTSB evaluated 12 straps, and found they were between 10 to 50 percent of their breaking force—the maximum a material can withstand.

All three passengers who were killed were in the same car. A rolling assembly attached and hit a car, which then “essentially became a missile as it traveled across the southbound lanes of Interstate 5.”

The fatalities most likely occurred, the investigation found, from both trauma from the initial hit and from the ejections caused by the collision.

Among the ejections was a child’s car seat, which was empty—a parent had just removed the infant for a diaper change a few minutes before. It’s possible that NTSB will recommend some kind of anchoring system.

“In my opinion I believe that [if a train that] had equipment that met North American or United States safety requirements been involved in this accident we would not have seen any rolling assemblies or trucks separate, and contribute to the overall severity of the injuries,” said Mike Hiller, an NTSB investigator.

“New people are there” at FRA now, said board member Jennifer Homendy in the meeting. “They have the opportunity to do the right thing this time. So does Amtrak.”

Next steps

WSDOT, which is learning about the findings in real time, didn’t immediately have any detailed comment. Spokesperson Janet Matkin said the agency needs time to “review them in detail.”

“Over the next few weeks, all the agencies involved will work together to determine next steps for Amtrak Cascades service,” said Matkin.

Wednesday, WSDOT announced that, working on the NTSB’s recommendation, it would be removing the Talgo 6 train configuration from service “as soon as possible.”

“Amtrak is working with WSDOT to determine how to address equipment needs moving forward and how we’ll provide Amtrak Cascades service without the Talgo Series 6 trains,” read a prepared statement. “There are four Talgo Series 6 trainsets currently in service, two sets owned by WSDOT and two sets owned by Amtrak. Evaluating what alternative passenger equipment is available and how scheduled train service in the Pacific Northwest is affected will inform our next steps.”

“While Sound Transit does not operate any service in the segment of track where the accident took place, as owner of the track we commit to closely reviewing the NTSB’s report and implementing recommendations in collaboration with Amtrak, the Washington State Department of Transportation, BNSF, and the Federal Railroad Administration,” read a statement prepared by Sound Transit. “Ahead of the report Sound Transit has already worked with partners to implement graduated speed limits and supplementary signs as well as crew communications requirements, as the NTSB today recommended. PTC is now fully operational in the corridor.”

The NTSB is considering amendments to its recommendations to the agencies involved, and should have a final accident report in three weeks, said Sumwalt.

This article has been updated to include comment from WSDOT and Sound Transit, plus additional follow-up comments from WSDOT.