In a report adopted today, the National Transportation Safety Board found that the Canadian National Railway Company's failure to properly maintain and inspect its track resulted in a rail shift that derailed an Amtrak train near Flora, Mississippi last year.
On April 6, 2004 Amtrak train No. 58, City of New Orleans, was traveling northbound at approximately 78 mph when it passed over a shift in the rail and the entire train consisting of a locomotive, a baggage car, and eight passenger cars derailed. One person was killed as a result of the derailment. The Board's report identified safety concerns with Canadian National's continuous welded rail maintenance and inspection procedures, Amtrak's emergency response training of its employees, and Federal Railroad Administration (FRA) oversight of both. NTSB Acting Chairman Mark Rosenker stated, "Rules and regulations exist to promote safety. What we have here is less than adequate work done by both Canadian National and the FRA and sadly it resulted in a fatal accident."
In January 2004 Canadian National welders removed a 12 foot 11 « inch portion of the east rail near the point of derailment. Because of the cold temperatures, when the piece of rail was removed the remaining rail contracted and as a result the replacement plug needed to be 2 « inches longer to fill the opening. According to Canadian National's policy, the additional rail was to be removed "prior to the onset of warm weather." Canadian National failed to remove the additional rail and warmer temperatures around the time of the accident caused the rail to expand.
A postaccident examination of the rail near the accident site found that about 50% of the rail anchors were ineffective. The Safety Board concluded that the inadequately restrained rail lifted out of the tie plates because of expansion caused by warm temperatures, resulting in the rail shifting and the gage widening, allowing the wheels of the train to drop between the rails.
During the investigation the Board learned that Canadian National's continuous welded rail policy required the welder to assess the rail anchors for 200 feet on each side of the repair. The work report submitted by the welder for the January 2004 repair did not indicate any problems with the rail anchors at the accident site. Additionally, a Canadian National track inspector, the track foreman, and the track supervisor visited the repair site on separate occasions at least one month before the accident. None of the Canadian National employees indicated any necessary repairs to the rail anchoring near the repair site even though the anchoring pattern clearly was not in accordance with Canadian National's policy.
The Board concluded that track employees at multiple levels did not follow or ensure adherence to Canadian National's written instructions for maintaining continuous welded rail. Had the employees who maintained the track followed the written procedures the rail shift likely would not have occurred. The Board recommended that Canadian National establish an audit program to verify that employees follow current written track maintenance and inspection procedures.
The FRA's track inspector had conducted two recent track inspections prior to the derailment. Although the inspector noted track deficiencies no defects were filed and therefore Canadian National was not required to make any repairs. The Board's report concluded that FRA oversight was not effective in ensuring corrective action would be taken and recommended that the FRA emphasize to track inspectors the importance of enforcing a railroad's own continuous welded rail program.
Although it was not a factor in this accident, the Safety Board's investigation also examined Amtrak's crewmember emergency preparedness training and determined that 4 of the 12 crewmembers involved in the accident had not received emergency preparedness training in accordance with FRA requirements. The Amtrak crew performed their emergency tasks well; however to promote safety in the future, the Board recognized that Amtrak was not assuring that all of its crewmembers received emergency preparedness training and recommended that Amtrak provide to the Board, within 90 days, a schedule for training all employees who are not currently in compliance with FRA regulations for emergency preparedness training. The Board also cited the FRA for not conducting periodic audits of Amtrak's emergency preparedness training program and recommended that the FRA establish an audit and enforcement program to verify that Amtrak complies with the FRA's emergency preparedness training regulations.
A synopsis of the report, including a complete list of the Conclusions and Recommendations, can be found on the Board's website, www.ntsb.gov.