Posts Tagged ‘NTSB investigations’

NTSB Wants Changes in Track Protection

October 1, 2021

The National Transportation Safety Board wants Amtrak and the Federal Railroad Administration to ban the practice of using watchmen to notify track worker of approaching trains in areas where positive train control offers additional safety features.

The recommendation was included in an NTSB report about an April 24, 2018, accident in which an Amtrak watchman was killed in Bowie, Maryland, when he was struck from behind by a northbound Amtrak train while focused on the movement of a southbound MARC commuter train.

The report said the probable cause of the accident was “Amtrak’s insufficient site-specific safety work plan for the Bowie project that (1) did not consider the multiple main tracks in a high-noise environment and (2) did not provide the rail gang watchman with a safe place to stand,” leading to him standing on an active track.

NTSB noted in its report that PTC systems can automatically slow trains through work zones.

NTSB Issues Report on CSX Pa. Derailment

December 10, 2020

Improper use of hand brakes was the probable cause of a 2017 CSX derailment in Hyndman, Pennsylvania, that resulted in 1,000 people being evacuated and property damage of $1.8 billion.

The National Transportation Safety Board said hand brakes on empty rail cars were set improperly.

It found that placement of empty cars at the front of the train consist led to the build-up of longitudinal and lateral forces that, along with tread buildup on the 35th car in the consist, led that car to be the first to derail.

The derailment occurred before dawn on Aug. 2, 2017.

The train had 70 cars of hazardous materials, including a car carrying propane that caught fire and cars carrying molten sulfur and asphalt that leaked.

The fire drove fire fighters away from the scene due to smoke and high levels of sulfur dioxide from the smoldering molten sulfur.

The fire was not extinguished until two days later and the evacuation order remained in place for three days.

The NTSB had three recommendations for CSX, one for the Federal Railroad Administration, one for the Association of American Railroads, and one for the Security and Emergency Response Training Center.

For CSX, the board recommended revising rules on building trains to place large blocks of empty cars near the end of a consist; prohibiting the use of hand brakes on empty cars to control train speed; and incorporating lessons about the hazards of fire in jacketed pressure tank cars in first-responder training and outreach.

For the FRA, the board recommended issuing guidance to develop risk reduction programs.

Such a program was not required at the time of the derailment but one was mandated under a rule published in February 2020 and to become effective in August 2021.

For the AAR, the NTSB recommended working with member railroads to develop those programs.

For the response training center, the NTSB recommended incorporating lessons from the accident into first-responder training programs.

NTSB To Hold Hearing on CSX Carey Collision

August 7, 2020

The National Transportation Safety Board will make its final determination on Sept. 15 of the likely cause of a 2019 collision between two CSX trains near Carey, Ohio.

The Board will conduct a virtual hearing at 9:30 a.m. on that day that will be webcast.

No members of the public, STB staff or members will be gathered in one location for the proceeding.

The crash occurred on Aug. 12, 2019, and caused both trains to derail.

The lead locomotive and four cars of a westbound train turned onto their sides while 21 cars of an eastbound train derailed.

The crew members involved suffered minor injuries and damage from the wreck was an estimated $4.9 million.

During the meeting, the Board will vote on the findings, probable cause and recommendations as well as any changes to the draft final report.

A link to the hearing  will be available at ntsb.windrosemedia.com

NTSB Releases Preliminary CSX Ohio Crash Report

October 12, 2019

A National Transportation Safety Board investigation of the August collision of two CSX trains in Ohio is focusing on train crew distractions, crew resource management, and current railroad operating rules for positive train control.

The NTSB this week released a preliminary report on the collision near Carey, Ohio, on the Columbus Subdivision in which local train H702 rammed into the W314, a 110-car frac sand train.

The report said the crash occurred in PTC territory although the locomotive of the local was operating at the time of the early morning incident with its PTC apparatus in restricted mode while the PTC system on the frac sand train had been disabled due to a malfunction.

“The [local] crew’s first job assignment was to set out 30 empty cars in Carey,” the report said.

“CSX instructions specify that for trains operating with active PTC, crews performing pickups, set offs, or other switching activities including shoving movements must: (1) Stop the train/locomotive; (2) Use restricted mode for the PTC system. In restricted mode, the PTC system allows train movement at restricted speed and no longer automatically stops the train before it can violate a red (stop) signal.”

After setting out 30 of his train’s 176 cars the conductor planned to return to the head end aboard a railroad shuttle van.

“The engineer of train H70211 departed with the PTC system still in restricted mode and continued westbound for about 2 miles to CP Springs,” the report said.

“Preliminary event recorder data indicated the train speed never exceeded 20 mph (upper limit threshold of CSX restricted speed rule). The train continued past the red signal at CP Springs and collided with the sixth railcar of the eastbound train W31411.”

The report said the W314’s PTC system had failed while that train was under the control of another crew and had been disabled.

“The crew involved in the accident notified the CSX dispatcher of the disabled PTC system prior to departing Garrett [Indiana] and were given permission to proceed to Columbus, where the system could be repaired,” the NTSB preliminary report says.

The crew of W314 told NTSB investigators that signal indications showed that their train would diverge from the single main track onto main track 2 at CP Springs.

“They stated that they saw the westbound train approaching CP Springs on main track 1 and noted the locomotive headlight was on bright,” the NTSB report said.

“The eastbound train engineer said that he flashed his headlight to indicate to the westbound train engineer to dim the locomotive headlight but received no response.”

After the collision, the lead locomotive of the H702 derailed along with four trash cars. Twenty-one of W314’s frac sand cars, in positions six through 26, derailed.

The engineers of both trains were treated for minor injuries and all crew members of both trains were given drug and alcohol tests.

Truck was on Crossing at Time of Crash

February 23, 2018

An on-board camera has shown that the garbage truck that was struck by an Amtrak special on Jan. 31, had entered a grade crossing after the crossing gates had gone down.

The National Transportation Safety Board said this week that the forward-facing camera in the lead locomotive showed that as the crossing came into view, the gates were down and the garbage truck was on the tracks at the grade crossing.

The NTSB said that witnesses to the crash reported the truck had entered the crossing after the gates were down at the crossing near Crozet, Virginia.

The special was carrying Republican members of Congress to an annual political retreat at the Greenbrier resort hotel in White Sulphur Springs, West Virginia.

A passenger in the truck was killed and another suffered serious injuries. The truck driver came away with minor injuries.

Three Amtrak crew members and three passengers also suffered minor injuries.

The preliminary NTSB report said that the crossing has advance warning signs and pavement markings on its approach. It is equipped with crossbuck signs, warning lights, bells and gates.

The collision caused the front axle of the lead P42DC locomotive to derail, although it remained upright.

The NTSB will later release a finding of probable cause and issue safety recommendations.

NTSB Wants Screening for Sleep Disorders

February 16, 2018

The National Transportation Safety Board wants the Federal Railroad Administration to require railroads to medically screen “safety-sensitive” employees for sleep disorders.

The recommendation came in a special investigation report about two end-of-track collisions at commuter train stations in New Jersey and New York.

In a separate report, the NTSB said last week that both accidents, which involved commuter railroads in the New York City area, were caused by engineer fatigue resulting from undiagnosed and untreated obstructive sleep apnea.

In both accidents trains struck end-of-track bumping posts and continued into the waiting rooms of the stations.

In a news release, the MTSB said both incidents had “almost identical” probable causes and safety issues.

The NTSB also called for the use of technology such as positive train control in terminal stations and improving the effectiveness of system safety program plans to improve terminal operations.

The New Jersey accident, which occurred on Sept. 29, 2016, and involved a New Jersey Transit train in Hoboken, killed one person and injured 110.

The other accident involved the Long Island Rail Road and occurred on Jan. 4, 2017, at the Atlantic Terminal in Brooklyn, New York. That incident injured 108.

Ex-NTSB Head Says Accidents Will Continue to Occur Until PTC is Installed and Implemented

February 13, 2018

A former head of the National Transportation Safety Board believes that accidents such as the one that killed two Amtrak crew members in South Carolina on Feb. 4 will continue until positive train control is fully installed and implemented.

Deborah Hersman said in an interview with Trains magazine that two recent derailments involving Amtrak that resulted in fatalities could have been prevented had PTC been in place at the time of the accidents.

Hersman said those accidents are especially frustrating because PTC is designed to prevent head-on collisions and speed-related incidents.

Excessive speed figured in a December derailment of an Amtrak Cascades train in Washington State while a misaligned switch has been implicated in the head-on crash of the southbound Silver Star with a parked CSX auto rack train.

“History just keeps repeating itself and we’re not learning from past mistakes fast enough to save lives,” she said.

Hersman was appointed to the NTSB in 2004. She was named chair of the board in 2009. Since 2014, she had served as president and CEO of the National Safety Council.

In the interview with Trains, Hersman noted that the NTSB has been calling for the implementation of PTC since 1990.

She said the number of accidents that might have been avoided had PTC been in place has continue to grow.

Following a head-on collision between a Los Angeles commuter train and a Union Pacific train in 2008, Congress adopted legislation requiring Class I railroad mainlines that haul hazardous materials or routes with regularly scheduled passenger service to have PTC.

The deadline was to have been at the end of 2016, but was extended by Congress to the end of 2018.

By law railroads required to have PTC must show that they have installed it by the end of this year. Failing that, they must show they have made substantial progress to seek an extension to 2020, something Hersman said would be disingenuous.

“We keep kicking the can down the road,” she said. “The pressure is on in the next 10 months because having PTC close to being installed is not close enough.”

NTSB Says Amtrak Engineer Applied Brakes, Sounded Horn Seconds Before Fatal Crash

February 5, 2018

The National Transportation Safety Board said on Monday afternoon that the engineer of Amtrak’s southbound Silver Star had applied the train brakes seconds before it struck a parked CSX freight train in a siding in Cayce, South Carolina.

The engineer also sounded his locomotive’s horn for three seconds.

NTSB investigators have said that a misaligned switch routed Amtrak train No. 91 into the path of the CSX train, which did not have a crew aboard at the time of the collision early Sunday  morning.

Chairman Robert Sumwalt said investigators found the data event recorders of Amtrak P42DC No. 47 undamaged in the wreckage.

The Amtrak engineer and an Amtrak conductor in the cab of the locomotive were killed in the crash, which also left 116 people aboard the train injured.

Sumwalt said the data showed that seven seconds before impact, the locomotive horn sounded for three seconds. The train was traveling at 56 miles per hour at that point, which was slightly slower than the 59 mph top speed allowed at that location.

Five seconds before impact, the brake pipe pressure began decreasing, indicating that the train brakes were being applied. The engineer had also moved the throttle from full to idle, which dropped the train’s speed to 54 miles an hour.

Three seconds before the collision, the emergency brakes were applied.

Sumwalt said the force of the collision moved the lead CSX locomotive 15 feet back from its location.

The switch that is the focus of the investigation was described as a hand-thrown switch that was found to have been locked into position to route a train from a mainline track into a siding.

The CSX train was sitting stationary 659 feet from the switch. Sumwalt indicated that aligning the switch for a straight move on the main would have been the responsibility of a CSX employee.

“We want to understand why that was the case,” Sumwalt said of why the switch was aligned as it was.

He said investigators found no mechanical problems with the switch.

Thus far, NTSB personnel have interviewed the CSX engineer, conductor, dispatcher, and a trainmaster. They plan to interview the surviving Amtrak crew members on Tuesday.

Earlier reports indicated that the signal system in the area of the crash was in the process of being upgraded and that trains were operating under track warrants issued by the dispatcher.

Sumwalt declined to reveal what the CSX employees said during the interviews.

He also declined to assess any blame. “I’m confident that our investigators will be able to piece this back together,” Sumwalt said.

2 Dead, 110 Hurt When Amtrak’s Silver Star Collides Head-on With CSX Auto Rack Train

February 5, 2018

Two Amtrak crew members were killed and more than 100 injured early Sunday morning when the Miami-bound Silver Star was misrouted into the path of a parked CSX freight train.

The accident happened at 2:35 a.m. in Cayce, South Carolina, about 10 miles south of a the train’s previous station stop at Columbia, South Carolina.

Officials said Train No. 91 had 147 aboard and 110 of them were reported to have suffered injuries ranging from minor cuts to broken bones. Nine of those aboard were Amtrak employees.

Killed were Amtrak engineer Michael Kempf, 54, of Savannah, Georgia, and conductor Michael Cella, 36 of Orange Park, Florida.

Dr. Eric Brown, the executive physician for Palmetto Health,  said six people were admitted to hospitals for more severe injuries, including head trauma.

National Transportation Board Chairman Robert L. Sumwalt said on Sunday afternoon that the switch had been manually “lined and locked” to divert the Amtrak train into the freight train.

“Of course key to this investigation is learning why that switch was lined that way because the expectation is the Amtrak would be cleared and would be operating straight down,” Sumwalt said.

Amtrak CEO Richard Anderson said during a conference call with reporters that before the crash the Amtrak crew was communicating with a CSX dispatcher by phone because a signaling system that governs traffic in the area was down for maintenance.

Authorities said investigators are still trying to determine how fast the Silver Star was going at the time of the collision, but the top speed there is 59 mph.

Sumwalt said the CSX train had two locomotives and 34 empty auto rack cars. It had unloaded automobiles on the west side of the main line and then used it to back into a siding on the east side of the main line.

“We were able to see that it was actually literally locked with a padlock to make it lined to go into the siding,” Sumwalt said of the switch on the main.

He said investigators will focus on why the switch wasn’t restored to its normal position before Amtrak No. 91 arrived.

NTSB personnel at the scene retrieved a front-facing video camera from Amtrak P42DC No. 47 and sent to their laboratory in Washington for review. The train’s event data recorder had not been located as of Sunday evening.

“I can tell you there’s catastrophic damage to each of the locomotives,” Sumwalt said. “In fact, I would say that the Amtrak locomotive would be not recognizable at all.”

The consist of the Amtrak train included a P42 locomotive, three Amfleet coaches, an Amfleet cafe lounge, two Viewliner sleepers and a baggage car.

Sumwalt said the crash could have been avoided if positive train control had been in operation at the time.

About 5,000 gallons of diesel fuel was spilled after the collision, but authorities said it posted “no threat to the public at the time.”

Passengers who were not injured or had been treated for injuries were taken to a middle school for shelter.

They were later put aboard chartered buses to continue their journey southward.

Rail Related Deaths Rose in 2016

November 28, 2017

The National Transportation Safety Board reported that 733 people were killed in 2016 in railroad related accidents, an increase from the 708 who died in 2015.

Most of the fatalities, 487,  involved people trespassing on railroad property.

Total transportation-related fatalities in 2016 were also up by 2,030 over 2015.

Highway accidents claimed the lives of 95 percent of the 39,339 who died last year.

“Unfortunately, we continue to see increases in transportation fatalities,” said NTSB Chairman Robert Sumwalt. “We can do more, we must do more, to eliminate the completely preventable accidents that claim so many lives each year.”

He called for implementation of the 315 open safety recommendations related to the agency’s most wanted list of transportation safety improvements

The list includes such recommendations as reducing fatigue-related accidents and improving transit-rail safety oversight.