Investigators Determine Cause of 2016 Philly-Area Train Crash

May 24, 2018

“Deficient safety management across many levels of Amtrak” was the cause of a train crash in Chester that killed two workers and injured 39 passengers, according to The National Transportation Safety Board.

The crash occurred in April 2016, when a southbound Amtrak train struck a backhoe on the track, killing two railroad workers. Last month, the NTSB announced that it had concluded its investigation of the crash and released a synopsis of findings. Investigators found “20 active failures of more than 2 dozen unsafe conditions” and noted Amtrak had failed to prioritize safety.

Lack of Communication, Safety Devices

There were four tracks at the site of the crash; track 2 was closed to train traffic and undergoing maintenance at the time. When workers are on or near tracks and using large equipment, federal law requires the worker in charge to issue a “foul” – a verbal or written warning to train conductors to reduce speed and use caution when approaching the area.

According to a separate internal investigation by Amtrak, on the morning of the crash, the night foreman removed fouls on tracks 1, 3, and 4, at 7:30 a.m., and the day foreman did not issue fouls at the beginning of his shift. He told NTSB investigators that he assumed the fouls were still in place when he began his shift. Because he did not issue new fouls for the day crew, the train conductor had no warning that workers were in the area and approached at full speed, striking the backhoe at 7:50 a.m.

The NTSB said that if the foremen had communicated about the transfer of fouls, the accident likely would not have occurred. And the accident would have been prevented, the NTSB said, had either of the foremen used track shunts – devices that send a signal to the train operator that a section of track is occupied.

Company Culture as a Risk Factor

The NTSB said, “The lack of consistent knowledge and vision for safety across Amtrak’s management created a culture that facilitated and enabled unsafe work practices by employees.” Specifically, the NTSB said Amtrak:

• Didn’t have a viable reporting system in place to collect critical safety information
• Had deficient safety programs that failed to provide first-line safety oversight
• Failed to enact random drug-testing to ensure its employees were drug-free.

The two men who died in the crash had drugs in their system – cocaine in one worker, and morphine, codeine, and oxycodone in the other worker. The conductor tested positive for marijuana, although it’s unclear whether he was drug-impaired at the time of the crash.

New Regulations

At the time of the crash, only conductors were subject to random drug-testing. But federal regulations now require rail companies to randomly drug-test maintenance workers, too. And a new law requiring rail companies to test all workers for opioid use goes into effect Jan. 1.

These new regulations may help protect maintenance workers and rail passengers from harm. But if rail companies continue to be lax about safety, more accidents may occur.