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A weak safety culture led to the 2016 derailment of an Amtrak train that killed two employees, according to a report published Tuesday by the National Transportation Safety Board.
A backhoe operator and a track supervisor were killed in the April 2016 incident involving Amtrak train 89 near Chester, Pennsylvania, traveling from Philadelphia to Washington, D.C., while 39 people were injured, according to a statement by the NTSB.
The Chester accident investigation revealed 20 active failures of more than two dozen unsafe conditions, many involving safety rule violations and risky behaviors by workers, according to the NTSB’s report.
“Amtrak’s safety culture is failing and is primed to fail again, until and unless Amtrak changes the way it practices safety management,” NTSB Chairman Robert L. Sumwalt said in the statement. “Investigators found a labor-management relationship so adversarial that safety programs became contentious at the bargaining table, with the unions ultimately refusing to participate.”
The NTSB determined that allowing a passenger train to travel at maximum authorized speed on unprotected track where workers were present, the absence of shunting devices, the foreman’s failure to conduct a job briefing at the start of the shift, all coupled with numerous inconsistent views of safety and safety management throughout Amtrak, led to the accident, according to the statement.
“Amtrak’s safety programs were deficient and failed to provide effective first-line safety oversight,” the NTSB said in its report. “Amtrak did not have a viable reporting system in place to collect safety critical information. The lack of consistent knowledge and vision for safety across Amtrak’s management created a culture that facilitated and enabled unsafe work practices by employees.”
While the NTSB determined that drug use was not a factor in this accident, it was symptomatic of a weak safety culture at Amtrak, as post-accident toxicology determined that the backhoe operator tested positive for cocaine, the track supervisor tested positive for codeine and morphine, and the locomotive engineer tested positive for marijuana, according to the statement.
“Although there was no operational evidence of impaired performance by the engineer, his use of marijuana was illicit and had not been deterred by his participation in the U.S. Department of Transportation drug testing program and any previous marijuana use had not been detected by random drug testing,” the NTSB said. “Amtrak did not effectively assure that its employees, especially those in safety-sensitive positions, were drug-free while performing their public transportation duties.”
“Had the two roadway workers used cocaine, codeine or morphine with some regularity, been subject to random urine drug screening and been selected for testing, their use of cocaine and opiates may have been detected before the accident,” the NTSB continued. “The absence of a random drug testing program for maintenance-of-way employees at the time of the accident meant there was no effective program to deter the maintenance of way employees from using drugs. The participation of the two roadway workers in the pool for random testing might have deterred them from using cocaine and opiates.”
Amtrak said it has a team in place that will immediately review NTSB’s safety recommendations and look to implement them, according to a special employee advisory distributed on Tuesday. The organization said it has already taken steps toward building a stronger safety culture such as improving communication and roadway worker protection training; organizing its safety, compliance and training resources into one department; revising and expanding its drug and alcohol policy; and committing to maintaining an environment where employees are encouraged to report unsafe conditions without fear of retaliation.
“The important message we want you to take away from today is that we’ve been in the process of transforming our safety culture since this incident,” Amtrak said in its advisory. “In the 19 months since the train 89 event, we have taken a series of actions to improve workplace safety at Amtrak, including the implementation of many of the actions discussed by the NTSB (Tuesday).”
Amtrak's cap on liability would increase to $500 million from the current $200 million if a bill introduced in the Senate becomes law.