​​​Mr. William J. Flynn
Chief Executive Officer
Amtrak
1 Massachusetts Ave. NW
Washington, DC 20001

Dear Mr. Flynn:

Today, the National Transportation Safety Board (NTSB) issued its final report on our investigation into the April 24, 2018, fatality of an Amtrak rail gang watchman who was struck by Amtrak train 86 in Bowie, Maryland. Regrettably, the circumstances of this roadway worker’s death were tragically familiar. The watchman—one of three tasked with protecting the safety of roadway work groups performing track maintenance on a main track—was placed near the end of a curve in the track. While the center track was occupied by maintenance equipment and no trains were operating, train movements on the two immediately adjacent tracks were allowed to continue as scheduled. The only protection for the roadway workers on the in-service tracks was the use of train approach warning (TAW). As the watchman was focused on his work crew and a southbound Maryland Area Rail Commuter (MARC) train servicing one adjacent track, he was unaware of northbound Amtrak train 86 approaching from behind him on the other adjacent track. He was struck and killed.

The Rail Safety Improvement Act of 2008 mandated that all Class I and passenger railroads fully implement positive train control (PTC) systems. Thanks to a multi-billion-dollar effort by your railroad and others, that requirement was implemented nationwide on December 31, 2020. PTC is a technology-based system to prevent train accidents caused by human error, including train-to-train collisions, overspeed derailments, incursions into established working limits, and movements of trains through a switch left in the wrong position. TAW, however, does not require the establishment of working limits and, therefore, circumvents the protections that would be provided by PTC in controlled track territory. In short, the decades of funding, research, equipment, and training you have put into the implementation of PTC is being undone by the continued use of TAW.

In February 2017, the Fatality Analysis of Maintenance-of-way Employees and Signalmen (FAMES) Committee estimated that in the 20 years following the adoption of the Roadway Worker Protection Rule, the use of TAW was involved in 13 accidents, resulting in the deaths of 16 roadway workers. We at the NTSB have continued to investigate accident after accident in which the shortcomings of TAW as a method of on-track safety have been laid bare:

• On April 3, 2016, southbound Amtrak train 89 struck a backhoe occupied by a roadway worker in a work zone near Chester, Pennsylvania. The train had been authorized to operate​ at 110 mph through the work zone. Two roadway workers were killed, and 39 others were injured. ​​
• On January 17, 2017, a BNSF Railway freight train struck and killed a watchman and one other roadway worker in Edgemont, South Dakota, as a group of three workers cleaned snow and ice from a track switch on the main track.
• On June 10, 2017, a road crew foreman stepped into the path of a Long Island Rail Road train at the Queens Interlocking in Queens Village, New York, after the train had sounded its horn to warn the roadway work group of its approach. The foreman was struck and killed.

In our final report on the Queens Village accident, we issued Safety Recommendation R-20-6 to the FRA, calling for the agency to define those circumstances under which the use of train approach warning are simply unacceptable. Although the FRA has thus far disagreed with this recommendation, the circumstances of the Bowie, Maryland, accident prompt us at the NTSB to put into clear and unambiguous language the step the FRA must take to protect on-track workers nationwide:

Modify Title 49 Code of Federal Regulations Part 214 to prohibit the use of train approach warning in controlled track territory during planned maintenance and inspection activities. (R-21-3​)

Whether or not the FRA acts promptly to implement this needed safety recommendation, you need not wait to implement immediate and positive change for the safety of your roadway workers. The practice of TAW places the sole responsibility for managing roadway worker risk upon lookouts and watchmen, while requiring them to monitor, simultaneously, such dynamic elements as train speed, track characteristics, sight distance, noise, and environmental conditions. When such alternatives as exclusive track occupancy, foul time, and train coordination exist, the continued use of TAW as a method of on-track safety is a deadly risk that your roadway workers cannot be asked to bear.

The NTSB looks to your leadership to protect rail workers and end the practice of TAW on our nation’s railways.

Sincerely,

Original Signed By

Jennifer Homendy
Chair

cc: 

Mr. Timothy T. Tenne
Senior Director
Standardization and Evaluation

​Mr. Justin A. Meko
Vice President
Safety, Training and Compliance

Mr. Chuck Baker
President
American Short Line and Regional
Railroad Association

Mr. Ian Jefferies
President and Chief Executive Officer
Association of American Railroads

Mr. Paul P. Skoutelas
President
American Public Transit Association

Mr. Greg Regan
President
Transportation Trades Department
AFL-CIO

Mr. Dennis R. Pierce
President
Brotherhood of Locomotive Engineers
and Trainmen

Mr. Freddie Simpson
President
Brotherhood of Maintenance of Way
Employees​