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Safety Recommendation Details

Safety Recommendation R-18-024
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 scheduled 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 Employes 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 THE FEDERAL RAILROAD ADMINISTRATION: Issue a guidance document railroads can use to assess their on-track safety program to ensure it encompasses the role of signal and train control equipment, including redundant protection, such as supplemental shunting devices to protect roadway workers and their equipment.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Railroad
Location: Chester, PA, United States
Is Reiterated: No
Is Hazmat: 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 #: RSR-18-03
Accident Date: 4/3/2016
Issue Date: 10/4/2018
Date Closed:
Addressee(s) and Addressee Status: FRA (Open - Unacceptable Response)

Safety Recommendation History
From: NTSB
Date: 9/16/2019
Response: On February 23, 2019, in response to Safety Recommendation R-08-6, you told us that, as part of the National Safety Program Plan, you were conducting an audit as an enforcement activity to follow up with relevant railroads regarding their adoption of redundant signal protection. You acknowledged that some railroads had implemented, or were actively implementing, redundant signal protection systems or procedures, and you promised to send us a summary following the audit. On April 22, 2019, we classified Safety Recommendation R 08 6 “Open—Unacceptable Response” because you did not provide us the summary of your audit results. We believe that your audit results are also relevant to this recommendation. Again, we request that you please share your findings with us so that we can evaluate the effectiveness your audit. Pending our receipt and review of such a summary, Safety Recommendation R-18-24 is classified OPEN--UNACCEPTABLE RESPONSE.

From: FRA
Date: 4/30/2019
Response: -From Ronald L. Batory, Administrator: FRA agrees with the NTSB's conclusion that the cause of the accident was the failure of Amtrak employees to comply with Amtrak's own on-track safety (OTS) rules and procedures and Amtrak management's failure to provide and develop the proper safety culture to ensure rule compliance. FRA disagrees, however, with the NTSB' s determination that a contributing factor was FRA not requiring redundant signal protection. At the time of the Chester accident, Amtrak's own rules required the use of redundant signal protection in the form of supplemental shunting devices as part of its OTS rules and procedures. The two roadway workers in charge (RWICs) involved failed to follow that rule and the clear requirements of FRA's Roadway Worker Protection (RWP) regulation, specifically Title 49 Code of Federal Regulations (CFR) § 214.319(a)(3). This regulation requires that all affected roadway workers be notified and removed from the track, or provided an alternative form of OTS, prior to releasing the authority providing OTS. Accordingly, the NTSB's recommendation that FRA issue guidance that railroads can use to assess their on-track safety programs would do nothing to effectively address the probable cause of the Chester accident. Amtrak already had considered the role of signal and train control equipment in its OTS program and had an appropriate rule in place. As FRA has previously stated, FRA does not believe that the application of supplemental shunting devices is appropriate or necessary in all circumstances. 1 FRA does not believe that adopting a Federal requirement mandating the use of signal and train control equipment (or any other one specific mitigation measure) for redundant protection is warranted. Accordingly, FRA's RWP regulation at 49 CFR § 214.319(b) requires each railroad to determine how best to provide redundant signal protection given its particular operations, but does not require that a railroad implement a specific mitigation measure. As a result, issuing a guidance document, such as that recommended by NTSB, would be contrary to FRA's regulation. Further, FRA does not believe that any change in the existing regulation is justified. Of the 65 RWP fatalities recorded since initiating the RWP rule, only three were covered by 49 CFR §214.319(b). Yet, of those three, none related to redundant protection and none would have been prevented by NTSB' s proposal. Because FRA cannot issue a guidance document contrary to a supporting regulation, and because there is a lack of data justifying a regulatory change, FRA will take no further action toward this recommendation. FRA respectfully requests that the NTSB classify Safety Recommendation R-18-24 as "Closed-Reconsidered."

From: FRA
Date: 10/15/2018
Response: -From Karl Alexy, Deputy Association Administrator, Office of Railroad Safety: Thank you for the report Using Technology to Protect Maintenance-of-Way Employees, which was sent to the Federal Railroad Administration (FRA) on October 9, 2018. In the "Recommendations" section of the report, the National Transportation Safety Board (NTSB) issued Safety Recommendations R-18-24 and -25 to FRA. 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 the NTSB to prevent future accidents and save lives. FRA welcomes and will consider all recommendations that will further that goal. If you have further questions or concerns, please contact Mr. Kenton Kilgore, Program Analyst.

From: NTSB
Date: 10/4/2018
Response: On September 28, 2018, the NTSB adopted its accident report, Using Technology to Protect Maintenance-of-Way Employees, Chester Pennsylvania, April 3, 2016, RSR-18/03. The details of this safety recommendation report may be found at Among the safety recommendations are two issued to the Federal Railroad Administration, which can be found on page 5 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 these recommendations. When replying, please refer to the safety recommendations by number. We encourage you to submit your response to If it exceeds 20 megabytes, including attachments, please e-mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response.