WASHINGTON – Federal safety investigators found Tuesday that a culture of systemic safety lapses at Amtrak caused a collision between a passenger train and a backhoe that killed two people and injured 39 outside Philadelphia in April 2016.
Amtrak workers at the accident site didn’t have safety equipment that the railroad required to steer trains around repair work on tracks, which the National Transportation Safety Board ruled was a factor in the crash.
The board also found a combination of 20 cultural safety lapses — including the lack of a job briefing at the construction site before high-speed trains were allowed back on the track — among the unsafe conditions that caused the crash.
The board concluded that Amtrak sought to strictly enforce safety rules, but that management had such an adversarial relationship with unions that workers didn't report infractions.
“Despite the emphasis on rules compliance, investigators did not find a culture of compliance,” Board Chairman Robert Sumwalt said. “Rather, they found a culture of fear on one hand and a normalization of deviance from rules on another hand.”
The case involved an Amtrak train that slammed into a backhoe at 99 mph about 7:50 a.m. near Chester, Pa. The collision derailed the locomotive and destroyed the backhoe, killing the operator and a track supervisor, and injuring 39 passengers on the train. The crash caused about $2.5 million in damage.
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Safety board investigators found that one of four tracks in the area was closed for 55 hours for repairs. But the adjacent track, which was blocked by the backhoe, was only closed temporarily during each construction shift and was mistakenly left open for the passenger train.
The night foreman lifted the track closure at 7:29 a.m. while the backhoe remained on the track, investigators said. But the day foreman didn’t restore the track closure during a call minutes later, allowing the collision about 20 minutes after that, investigators said.
“Under no circumstances should you clear foul times with men and equipment fouling the track,” said Joe Gordon, who investigated track and engineering issues for the board.
Amtrak has an automatic-braking system that is intended to prevent train collisions and derailments from trains going too fast. In addition, workers have “supplemental shunting devices” that can be attached to the track near construction sites to change track signals that alert train engineers and dispatchers about where tracks are closed.
Despite Amtrak requiring the use of shunts at construction sites, investigators said workers at the accident site didn’t have them. Amtrak bought thousands of the devices after the accident, said Ryan Frigo, the lead investigator on the case.
“It’s taken blood and a loss of lives to actually require that,” Sumwalt said.
Investigators found 20 safety lapses that could have prevented the crash, including improper track closures, lack of work briefings, a lack of shunts and the use of cellphones for work calls.
“If any of these had been fixed, the accident might not have happened,” Gordon said.
Three workers tested positive after the accident for using drugs including opioids, cocaine and marijuana that could have impaired their abilities, but investigators said that didn’t play a role in the crash.
The Federal Railroad Administration changed its rules after the accident to begin randomly testing track repairmen for drug use.
Board investigators outlined hostile relations between Amtrak management and unions. Amtrak strictly enforced safety rules under threat of firing workers for violations, which investigators found led to a reluctance among workers to report infractions.
“Amtrak had such a focus on rules, but we found widespread non-compliance with the rules,” Sumwalt said. “That is ironic.”