Amtrak's challenge: Fix safety lapses that caused fatal 2016 crash in Chester

It's been a month since the nation's transportation watchdog found that simply following safety procedures could have prevented a 2016 Amtrak train crash in Chester that killed two railworkers and injured 39 passengers.

"Amtrak's safety culture is failing — and is primed to fail again — until and unless Amtrak changes the way it practices safety management," wrote Robert Sumwalt, chairman of the National Transportation Safety Board, after a Nov. 14 hearing in Washington.

Transportation safety officials, national legislators, and rail experts have some specific ideas on what fixes would be most effective and are waiting to see whether Amtrak and the Federal Railroad Administration, the agency that regulates rail travel in the United States, adopt recommendations that would protect the 31 million train passengers transported annually.

Among the 15 recommendations issued in November, the NTSB called on Amtrak and the FRA to improve technology and communication, and renew the focus on safety. NTSB recommendations are nonbinding but are acted upon about 80 percent of the time.

Amtrak has taken some steps toward improving safety, but a year and a half after the fatal train derailment, some significant safety gaps remain unresolved.

"I still take Amtrak trains," said Steven Ditmeyer, the principal officer at Transportation Technology and Economics in Virginia and a former FRA executive. "but I still have a bit of a residual concern that there still may be some gaps in the safety system."

The NTSB review also revealed faults in the FRA, raising concerns that the rail regulator isn't ensuring safe train travel. A 2016 FRA order that all railroads submit a safety plan has been universally ignored. Experts expressed concern that the FRA is understaffed and that rail isn't a priority for the Trump administration.

The FRA declined to comment.

On April 3, 2016, Train 89 en route to Savannah, Ga., hit a backhoe on the rails in Chester at about 100 mph. Two Amtrak workers on the tracks died and 39 passengers were hurt. Because of communications failures on the part of the night and the day foreman, protections that would have prevented a train from being routed onto a track undergoing maintenance were not in place. The train's engineer didn't know workers were in the area, and the workers had no idea a train was coming.

The NTSB found 24 separate safety failures, including a dispatcher making personal phone calls while on the job, a lack of backup safety tools that alert dispatchers to the presence of people on the tracks, and a supervisor who was lax on requiring workers to follow Amtrak's safety procedures.

The NTSB criticized Amtrak and labor unions for making safety routines a negotiable part of contract talks. Meanwhile, the two men killed and the train engineer all tested positive for drugs, though the NTSB didn't conclude that played a role in the crash. Amtrak has since required maintenance of way workers be subject to random drug screenings.

Overall, the NTSB found a "culture of fear on one hand," Sumwalt said last month, "and normalization of deviance from the rules on the other."

Individual mistakes, though, are the consequence of a systemic failure to combat a reality of human behavior, said Bill Keppen, a retired train engineer and transportation safety consultant.

"People get complacent," he said.

Bella Dinh-Zarr, an NTSB board member, emphasized in November that the railroad's Positive Train Control system — an automatic speed control system designed to sense obstacles on the track — could have prevented the deaths if Amtrak had installed a GPS device on the backhoe. PTC did not detect the backhoe because Amtrak maintenance equipment is not linked to the safety system.

"My background comes from public health and injury prevention," Dinh-Zarr said in an interview. "We know people are going to make errors. We need to find out ways that we can prevent those accidents from happening when there is human error."

Human error is the second most common cause of accidents on Amtrak, according to FRA data.

The NTSB recommended that the FRA require all railroads to install tracking devices on maintenance vehicles. Amtrak has evaluated GPS systems, Amtrak spokeswoman Christine Leeds said, but the company committed only to continuing to explore the technology.

Some railroads have adopted a GPS technology for maintenance vehicles, he said, and he argued to the FRA in a December memo that the lack of such trackers violated the 2008 federal law that required PTC to prevent "incursions into established work zone limits."

"Maintenance of way equipment and maintenance of way people need GPS receivers and data radios that communicate their activity to the dispatcher," said Ditmeyer, who participated in creating an early version of PTC. "The dispatcher should be able to see what's going on in the field."

Other experts agreed more comprehensive PTC would have helped in Chester but said any technology can be undermined by people who failed to follow the rules.

Workers should be able to report lapses that don't result in accidents without fear of being disciplined or punished, experts said. Amtrak had a "close-call" reporting program, according to the rail agency, but the NTSB found that workers were too afraid of reprisals to use it properly.

"The identification and reporting of unsafe conditions is at the heart of railroad safety," said Frederick Hill, spokesman for the Senate Commerce Committee, which has oversight of railroads. "Amtrak and its unions should work together to ensure a comprehensive and effective system for reporting dangerous situations."

More than a year after the Chester crash, Amtrak told the NTSB that it was still working to revise its reporting program.

The original failure that caused the Chester crash, said David Schanoes, a retired railway man who worked with Conrail and MetroNorth before entering consulting, was the night foreman's call to lift track protections while the backhoe was still on the tracks, and without coordinating directly with the day supervisor.

"You still have to train people in the rules and how to abide by the rules because there is no system that doesn't fail," Schanoes said.

Since the 2016 crash, Amtrak has created a new department that combined safety, training, and compliance tasks, and hired a vice president of safety to oversee it, according to a letter Amtrak sent to the NTSB before the November hearing. Changes include making safety procedures mandatory and not subject to labor negotiation, new training courses, and hiring people with expertise in creating effective safety programs.

Ditmeyer said safety systems should be clear and easy to follow. He cited Atul Gawande, a doctor and public health writer who emphasizes the importance of checklists.

"The employees aren't supposed to memorize them," Ditmeyer said. "They pull out these one-page checklists and they go through it and are sure they know what needs to be done."