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On April 3, 2016, about 7:50 a.m. eastern daylight time, southbound Amtrak train 89 (train 89) struck a backhoe with a worker inside at milepost 15.7 near Chester, Pennsylvania. The train was authorized to operate on main track 3 (track 3) at the maximum authorized speed of 110 mph. Beginning on the morning of April 1, Amtrak had cheduled track-bed restoration?ballast vacuuming—at milepost 15.7 on track 2 on the Philadelphia to Washington Line. Track 2 had to be taken out of service between control points Baldwin (milepost 11.7) and Hook (milepost 16.8) for the 55 hour duration of the project. As train 89 approached milepost 15.7, the locomotive engineer saw equipment and workers on and near track 3 and initiated an emergency brake application. The train speed was 106 mph before the emergency brake application and 99 mph when it struck the backhoe. Two roadway workers were killed, and 39 other people were injured. Amtrak estimated property damages to be $2.5 million. The accident investigation focused on the following safety issues: roadway worker protection, communication between dispatchers and foremen, lack of job briefing, and safety management. As a result of this investigation, the National Transportation Safety Board makes safety recommendations to the Federal Railroad Administration, Amtrak, Brotherhood of Maintenance of Way Employees Division, American Railway and Airway Supervisors Association, Brotherhood of Locomotive Engineers and Trainmen, and Brotherhood of Railroad Signalmen. The National Transportation Safety Board also reiterates a recommendation to the Federal Railroad Administration.
TO THE FEDERAL RAILROAD ADMINISTRATION: Enact Title 49 Code of Federal Regulations Part 270, System Safety Program, without further delay.
Original recommendation transmittal letter:
Open - Unacceptable Response
Chester, PA, United States
Preliminary Report: Railroad DCA16FR007
Amtrak Train Collision with Maintenance-of-Way Equipment, Chester, Pennsylvania
Safety Recommendation Report: Using Technology to Protect Maintenance-of-Way Employees
Addressee(s) and Addressee Status:
FRA (Open - Unacceptable Response)
Safety Recommendation History
Reiterated in the Railroad Accident Report RAR-19-01: Amtrak Passenger Train 501 Derailment DuPont, Washington December 18, 2017, Adopted on May 21, 2019 and published on June 24, 2019, notation number 58913 and accident number RRD18MR001. On April 3, 2016, about 7:50 a.m. eastern daylight time, southbound Amtrak train 89 struck and killed a worker inside a backhoe at MP 15.7 near Chester, Pennsylvania (NTSB 2017). As a result of this investigation, the NTSB identified the need for Amtrak to implement a formal System Safety Program, and issued recommendations to Amtrak to take this action. One of the challenges faced by all railroads in developing a formal System Safety Program, has been the failure of the FRA to enact its final rule. Many of the railroads have designed their System Safety Program but are apprehensive about implementing their plan because of concerns that modifications will be necessary after the System Safety Program regulation is fully enacted. At the time of the NTSB’s report on the accident in Chester, the FRA had delayed the rule’s implementation four times. As a result, the NTSB issued Safety Recommendation R-17-17 to the FRA: Enact Title 49 Code of Federal Regulations Part 270, “System Safety Program,” without further delay. (R-17-17) In the 2 1/2 years since the final rule was published, the FRA has granted six extensions that have delayed this rule until its currently scheduled effective date of September 4, 2019. In the years since the rule was published, accidents have continued to occur. In addition to the accident near Chester, Pennsylvania, and the accident in DuPont, Washington, the NTSB is also investigating the February 4, 2018, accident involving Amtrak train 91, which diverted from the main track through a hand-thrown switch into a siding and collided head-on with a stationary CSX Transportation freight train in Cayce, South Carolina (NTSB 2018b). The engineer and conductor of that Amtrak train died, and 92 passengers and crewmembers were transported to medical facilities. On April 22, 2019, pending implementation of the final rule, Safety Recommendation R-17-17 was classified “Open—Unacceptable Response.” The Chester accident occurred on Amtrak’s own property. As shown by this accident and others, Amtrak operates on host railroads throughout the United States. The system safety regulation would not be limited to Amtrak property and would be applicable to all of Amtrak’s operations including those on host railroads. With the regulation in place, the relationship between the host railroad and Amtrak would be better defined and Amtrak could present to the host railroads their regulatory obligations. The NTSB concludes that the repeated postponement of 49 CFR Part 270, “System Safety Program,” has delayed needed safety improvements for the passenger rail industry, rail employees, and the traveling public. Therefore, the NTSB reiterates Safety Recommendation R-17-17.
We are aware that before this recommendation was issued, you published the System Safety Rule on August 12, 2016. This rule requires that commuter and intercity passenger railroads develop and implement a system safety program to evaluate and manage safety risks. We are disappointed that, after 2 years, you have granted multiple extensions to this regulation that have delayed its effective date to September 4, 2019. In the years since the rule was published, accidents have continued to occur. In addition to the accident near Chester, Pennsylvania, we are currently investigating two railroad accidents involving Amtrak trains which may show the need for this recommendation. On February 4, 2018, southbound Amtrak train 91, diverted from the main track through a hand-thrown switch into a siding and collided head-on with a stationary CSX Transportation freight train in Cayce, South Carolina. The engineer and conductor of the Amtrak train died as a result of the collision, and 92 passengers and crewmembers on the Amtrak train were transported to medical facilities. In another accident, on December 18, 2017, southbound Amtrak train 501 derailed from a bridge near Dupont, Washington. Several passenger railcars fell off the bridge onto Interstate 5 and hit multiple highway vehicles. Three rail passengers were killed, and 57 passengers and crewmembers were injured. Additionally, 8 individuals in highway vehicles were injured. These accidents show the continuing need for all commuter and intercity passenger railroads to develop and deploy system safety programs. Pending issuance of the recommended requirement, Safety Recommendation R-17-17 is classified OPEN--UNACCEPTABLE RESPONSE.
-From Ronald L. Batory, Administrator: Since publishing the System Safety Program final rule on August 12, 2016, FRA received petitions for reconsideration from labor organizations and State and local transportation departments and authorities, including a request to stay the rule's effective date pending FRA's response to the petitions. FRA initially stayed the effective date of the final rule on February 10, 2017, and on November 30, 2017, last extended the effective date of the final rule until December 4, 2018. FRA convened a Railroad Safety Advisory Committee (RSAC) meeting on October 30, 2017, to discuss the petitions for reconsideration and comments received in response to the petitions for reconsideration. FRA is in the process of considering recent stakeholder feedback arising from the meeting to address the issues raised in the petitions. FRA respectfully asks that NTSB classify Safety Recommendation R-17-17 as "Open-Acceptable Response."
-From Karl Alexy, Director, Office of Safety Analysis: Thank you for the report, Amtrak Train Collision with Maintenance-of-Way Equipment, Chester, Pennsylvania, April 3, 2016, NTSBIRAR-17102, which was sent to the Federal Railroad Administration (FRA) on December 28, 2017. In Section 5.1 of the report, NTSB issued to FRA two Safety Recommendations, R-17-17 and R-17-18, as a result of its findings. Improving safety is FRA's top priority, and FRA will continue to work to make rail shipments as safe as possible. FRA is committed to working with NTSB to prevent future accidents and save lives. FRA welcomes and will consider all recommendations that will further that goal.
The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. On November 14, 2017, the NTSB adopted its report Amtrak Train Collision with Maintenance of Way Equipment, Chester, Pennsylvania, April 3, 2016, NTSB/RAR 17/02. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov.
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