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Safety Recommendation Details

Safety Recommendation R-17-027
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): Once Safety Recommendation R-17-26 is completed, implement the safety management system program throughout the company with resources sufficient to ensure that all levels of management and all labor unions involved with Amtrak operations accept and comply with the system.
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: Amtrak is working aggressively to implement the safety management system. In the past several months: 1. Amtrak's Board of Director's has passed a resolution directing industry leading SMS and PTC implementation. The board is routinely updated on progress. 2. A new safety policy has been developed and released 3. Multiple hazard identification and risk assessment procedures have been implemented 4. Safety metrics have been revised to add additional measurements of safety throughout the Amtrak system 5. A formal accident and incident investigation process has been implemented 6. Numerous company-wide safety communications have been released reinforcing our safety policy along with numerous departmental safety bulletins and alerts In advance of any regulatory requirement, Amtrak will be submitting its formal System Safety Program Plan, per FRA Part 270, to the FRA by November 1, 2018.

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.