A derailment and the fatalities of two railroad workers on April 3, 2016 has led to an investigation by the National Transportation Safety Board (NTSB). In this investigation, the NTSB will address the impacts of the accident, determine what caused the accident and will provide recommendations to prevent similar accidents from recurring. While the investigation is still underway, a wealth of information related to the accident is already available to begin the analysis. We will look at what is currently known regarding the accident in a Cause Map, a visual form of root cause analysis.
The first step of the analysis is to define the problem. This includes the what, when, and where of the incident, as well as the impacts to the organizational goals. Capturing the impacts to the goals is particularly important because the recommendations that will result from the analysis aim to reduce these impacts. If we define the problem as simply a “derailment”, recommendations may be limited to those that prevent future derailments. Not only are we looking for recommendations to prevent future derailments, we are looking for recommendations to prevent all the impacted goals. In this case, that includes worker safety: 2 workers died, public safety: 37 passengers were injured, customer service: the train derailed, property: the train and some construction equipment was damaged, and labor: response and investigation are required.
The analysis is performed by beginning with the impacted goals and developing the cause-and-effect relationships that led to those impacts. Asking “why” questions can help to identify some of the cause-and-effect relationships, but there may be more than one cause that results in an effect. In this case, the worker fatalities occurred because the train struck heavy equipment and the workers were in/on/near the equipment. Both of these causes had to occur for the effect to result. The workers were on the equipment performing routine maintenance. In addition, their watch was ineffective. When capturing causes, it’s important to also include evidence, which validates the cause.
We know the watch was ineffective, because federal regulation requires a watch for incoming trains that gives at least a fifteen second warning. Fifteen seconds should have been sufficient time for the workers to exit the equipment. Because this did not happen, it follows that the watch was ineffective.
The train struck the heavy equipment because the equipment was on track 3, the train was on track 3, and the train was unable to brake in time. It’s unclear why the heavy equipment was on the track; rail safety experts say heavy equipment should never be directly on the track. The train was on track 3 because it was allowed on the track. Work crews are permitted to shut off the current to preclude passage of trains into the work zone, but they did not in this case, for reasons that are still being investigated. Additionally, the dispatcher allowed the train onto the track. Per federal regulations, when workers are on the track, train dispatchers may not allow trains on track until roadway worker gives permission. It appears that in this case the workers either failed to secure permission to work on the track (thus notifying the dispatcher of their presence) or the work notification was improperly cancelled, allowing trains to return to the track, possibly due to a miscommunication between the night and day crews. This is also still under investigation.
While inspection of the cars and maintenance records found no anomalies, the braking system is under investigation to determine whether or not it affected the train’s ability to brake. Also under investigation is the Positive Train Control (PTC), which should have emitted warnings and slowed the train automatically. However, the supplemental shunting device, which alerts the signaling system that the track is occupied, and is required by Amtrak rules, was not in place. Whether this was sufficient to prevent the PTC from stopping the train in time is also under investigation. The conductor placed the train in emergency mode 5 seconds before the collision. As the train was traveling at 106 mph (the speed limit was 110 mph in the area), this did not give adequate time to brake. There should have been a flagman to notify the train that a crew was on the track, but was not. The flagman also carries an air horn, which provides another notification to the track crew that a train is coming.
Says Ashley Halsey III, reporting in The Washington Post, “Basic rules of railroading and federal regulations should have prevented the Amtrak derailment near Philadelphia on Sunday that killed two maintenance workers.” It appears that multiple procedural requirements were not followed, but more thorough investigation is required to determine why and what can be done in the future to improve safety by preventing derailments and worker fatalities.
To view the available information in a Cause Map, please click “Download PDF” above.