NTSB report: 'Culture of fear' present at Amtrak for 2016 accident

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Amtrak ACS64 No. 627 shortly after it crashed into a maintenance-of-way backhoe that was fouling a track on the Northeast Corridor near Chester, Pa., in April 2016.
National Transportation Safety Board
WASHINGTON — If Amtrak had deployed a familiar device that trips "stop" signals, it could have avoided an accident at Chester, Pa., on April 3, 2016, that killed two workers and injured 40 passengers on a southbound train, the National Transportation Safety Board ruled on Nov. 14.

Amtrak workers failed to protect the worksite with a cable — a shunt — designed to cause an electrical short that turns signals red to warn oncoming trains, according to NTSB findings. Amtrak train No. 89, the Palmetto, was out of New York heading for Savannah, Ga., when it struck a backhoe fouling the tracks about 7:50 a.m.

The NTSB cited several contributing factors: Track supervisors' failure at shift change to alert dispatchers of the ongoing work; a dispatcher distracted by personal phone calls; and a foreman's failure to assure that safety measures were in place. The NTSB could not determine if drug use was a contributing factor.

NTSB Chairman Robert Sumwalt said Amtrak's lack of a “safety culture” was the overall cause of the accident. Amtrak had a set of “cardinal rules,” and an employee breaking any one could fired, but the investigation found “more than two dozen unsafe conditions, and not all were rule-breaking by front-line employees.

“And despite the emphasis on rules and compliance, investigators did not find a culture of compliance … Rather, they found a culture of fear, on one hand, and normalization of deviance from rules on the other,” Sumwalt said. “A culture of fear and strong safety culture cannot coexist.”

Sumwalt also noted that there have been safety improvements by Amtrak and the Federal Railroad Administration since the accident.

Board Member T. Bella Dinh-Zarr added that positive train control should be used to protect work zones, and recommended that GPS or other technology be deployed to provide an independent means of telling dispatchers of work zone activity.

Amtrak officials said that safety is a core value for passengers and employees, “and we are committed to operating our nationwide network of services safely, effectively and efficiently,” a spokeswoman old Trains News Wire.

“We’ve been in the process of transforming our safety culture since this incident. 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 today,” she said.

An archive webcast of the NTSB meeting is online.

Related NTSB documents are also online.

NEWSWIRETrains News Wire

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