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Safety Recommendation Details

Safety Recommendation R-17-021
Details
Synopsis: 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.
Recommendation: TO AMTRAK (NATIONAL RAILROAD PASSENGER CORPORATION): Require supervisors to review train dispatchers’ foul time log sheets to verify whether supplemental shunting devices are being adequately applied.
Original recommendation transmittal letter: PDF
Overall Status: Open - Initial Response Received
Mode: Railroad
Location: Chester, PA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA16FR007
Accident Reports: Preliminary Report: Railroad DCA16FR007Amtrak Train Collision with Maintenance-of-Way Equipment, Chester, Pennsylvania​​Safety Recommendation Report: Using Technology to Protect Maintenance-of-Way Employees
Report #: RAR-17-02
Accident Date: 4/3/2016
Issue Date: 12/28/2017
Date Closed:
Addressee(s) and Addressee Status: Amtrak (National Railroad Passenger Corporation) (Open - Initial Response Received)
Keyword(s):

Safety Recommendation History
From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 7/6/2018
Response: -From Kenneth J. Hylander, Executive Vice President and Chief Safety Officer: The Amtrak Operating Practices Department implemented a change on February 1, 2018 for the dispatcher centers using the paper foul time sheet procedure. This change provides a check box for the dispatcher to mark if the field employee has requested a verification of a Track Occupancy Light (TOL) caused by the application of a Supplemental Shunting Device (SSD). If the TOL is visible the dispatcher will communicate this information and then make the mark in the appropriate check box “YES" under the SSD column. If the field employee does not request confirmation, the dispatcher will then check a box that would be labeled aN/A". The paper form has been completed. An efficiency testing category was added to document the application of the revised procedures. This change was communicated to supervisors by the Operating Practices group through an update to the efficiency testing program. Efforts are underway to apply the same process where the Electronic Foul Time Authority dialogue is applied. This would encompass changes to the {{Point and Click" (PAC) format as well as the Foul Time Dialogue within the original blocking dialogue window which would include a Foul Time Summary with a dedicated SSD Application Verification Column. This effort is to be included in the scope of work for current dispatcher system enhancement projects. These projects include replacing the current dispatching systems with an anticipated completion timeframe of 2020.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 12/28/2017
Response: 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. Among the Safety Recommendations are nine issued to National Railroad Passenger Corporation, which can be found on pages 69–70 of the report. The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days, detailing the actions you have taken or intend to take to implement the recommendations.