Human error, safety oversights caused 2017 Amtrak derailment that killed 3 near DuPont

An Amtrak train derailment near DuPont that killed three and injured dozens happened because the engineer lost track of where he was on the route and was going more than twice the speed limit when he hit a curve, the National Transportation Safety Board announced Tuesday.

The agency also blamed Sound Transit for not sufficiently mitigating the danger of the sharp bend, Amtrak for not better training the engineer, Washington State Department of Transportation for not ensuring the route was safe before green-lighting a passenger train and the Federal Railroad Administration for using rail cars beneath regulatory standards.

“The engineer was set up to fail,” said NTSB Chairman Robert Sumwalt.

Although federal officials released preliminary findings after the Dec. 18, 2017 crash, this is the first time investigators have offered a final determination of what happened.

State Sen. Steve O’Ban, R-University Place, released a statement Tuesday afternoon blasting Sound Transit, Amtrak and government agencies charged with safety procedures.

“I’m appalled at the incompetence and complete lack of accountability that created the chain of failure that day,” said O’Ban, a frequent critic of Sound Transit. “The victims of this accident were let down by a careless system of bureaucracy that dropped the ball again and again.”

Seattle-based Sound Transit issued a statement Tuesday afternoon, calling the derailment “a terrible tragedy that sears in the memory of all of us at Sound Transit.”

“While Sound Transit does not operate any service in the segment of track where the accident took place, as owner of the track we commit to closely reviewing the NTSB’s report and implementing recommendations in collaboration with Amtrak, the Washington State Department of Transportation, BNSF and the Federal Railroad Administration,” the agency said.

“Ahead of the report, Sound Transit has already worked with partners to implement graduated speed limits and supplementary signs as well as crew communications requirements, as the NTSB today recommended.”

The Sound Transit statement added that Positive Train Control, a technology that helps slow down trains going too fast for conditions, “is now fully operational in the corridor.”

Amtrak also issued a statement Tuesday.

“We remain deeply saddened by the loss of life and injuries due to this tragic event,” Amtrak said. “We continue to cooperate with the NTSB and will work with them to address their recommendations.”

Amtrak said it has already implemented a number of changes, including the creation of a new “safety organization” and the development of a strategic plan to “maximize the effective use of simulators in training, qualification and certification of Amtrak employees.”

There were 77 passengers and six crew members on board Amtrak Cascades 501 when the train made its first public run on a new route meant to shave 10 minutes off the ride from Seattle to Portland.

It departed in the dark at 6:10 a.m.

FILE- In this Dec. 18, 2017, file photo, cars from an Amtrak train that derailed lie spilled onto Interstate 5 in DuPont, Wash. Federal investigators say video aboard the Amtrak train that derailed in Washington state shows crews weren’t using personal electronic devices and that the engineer remarked about the speed six seconds before the train went off the tracks south of Seattle. (Bettina Hansen /The Seattle Times via AP, File) Bettina Hansen AP

About 7:40 a.m., the train left the tracks as the locomotive approached a sharp turn near Mounts Road, sending some rail cars off an overpass.

Thirteen of 14 cars came off the tracks, some of them falling on Interstate 5 below and hitting five vehicles and two semi-trailers.

One car was left dangling in the air.

Several panicked passengers called 911.

“An Amtrak train fell on the I-5 overpass,” one woman told dispatchers. “The train is hanging off the overpass. It’s landed on vehicles and there’s people like … there’s, there’s bodies laying everywhere.”

Emergency responders arrived quickly and took 62 people to local hospitals. A hazardous-materials team removed 350 gallons of diesel fuel that leaked from a train car.

Southbound I-5 was shut down while crews removed the wreckage with cranes and hauled it away on flatbed trucks.

It wasn’t a quick or easy process — the locomotive weighed 270,000 pounds and was more than 27 feet long.

I-5 did not reopen for two days, affecting about 60,000 drivers who use that stretch of freeway daily. Traffic on alternative routes backed up 16 miles in some areas.

Damages from the derailment were estimated to be $25.8 million.

Killed in the crash were Zack Willhoite, 35, and Jim Hamre, 61, longtime friends and railroad advocates. Benjamin Gran, 40 of Auburn, also died.

It took days before investigators could interview the 55-year-old engineer and 48-year-old conductor, both of whom were seriously injured.

Investigators said the train was going 78 mph when it rounded the curve. That’s 48 mph faster than the 30 mph speed limit.

amtrak curves AP photo by Elaine Thompson.JPG
People work at the curve leading to the railroad bridge where an Amtrak train derailed onto Interstate 5 two days earlier Wednesday, Dec. 20, 2017, in DuPont, Wash. The Amtrak train that careened off the overpass south of Seattle, killing at least three people, was hurtling 50 mph over the speed limit when it jumped the track, federal investigators say, when it derailed along a curve, spilling railcars onto the highway below. (AP Photo/Elaine Thompson) Elaine Thompson AP

The engineer appeared to apply the brakes but did not put the brakes in emergency mode.

He told federal officials he was aware of the sharp curve — he’d operated the locomotive three times on that track and observed the route another 7-10 times — but lost track of where the train was on the route.

The engineer did not see an advance-warning sign two miles before the 30 mph zone or a second speed limit warning less than a mile later, investigators said during Tuesday’s NTSB hearing .

“This sign was particularly important to him because it was one mile before the curve and the location where he had intended to begin braking to slow down for the curve,” said Michael Hiller, lead investigator on the accident.

About a half mile and 27 seconds before the curve, the train was going 82 mph. An alarm sounded in the locomotive’s cab and lights on two screens of the control panel began flashing.

However, Amtrak had not trained the engineer on that system, and he did not immediately know what the alarm meant. By the time he figured it out, it was too late.

“This failure to detect those signs suggests that he was not adequately prepared on the physical characteristics of the new territory,” said crash investigator Stephen Jenner.

Both the engineer and conductor were paying attention to the route and were not distracted. Fatigue, drugs and alcohol did not play a role in the derailment, according to the NTSB.

In fact, the engineer paid for his own hotel in Seattle the night before the inaugural run to ensure he was well rested.

He and the conductor had never worked together before.

The engineer was hired by Amtrak in 2004 and promoted to engineer in 2013. The conductor was hired in 2010.

Months after the crash, the conductor and some passengers filed lawsuits against Amtrak. The suits have yet to be resolved.

NTSB staff members on Tuesday made several suggestions to improve safety moving forward. Among them:

Give engineers more hands-on training and ensure they are familiar with all features on the route before getting behind the controls.

Educate all crew members on how to assist in the cab.

The conductor “saw his role as passive and to learn as much as he could,” Jenner said, indicating that even junior crew members could intervene if something goes wrong with a train.

Enhance signs at key locations to make sure engineers can see them.

The NTSB criticized both Sound Transit and Amtrak for not having up-to-date operating documents at the time of the derailment.

Those documents could have included ways to handle the accident curve and forced the engineer and conductor to communicate in that zone, possibly stopping the train if one of them did not see a sign.

Amtrak officials allegedly told investigators their plan was to create a “crew focus zone” to pay attention to the dangerous curve in January 2018, one month after starting service on the route.

Before approving the new route for passenger trains, Sound Transit did a safety verification report but did not address hazards or operations testing, “indicating a less than thorough safety review,” NTSB investigators said.

During that process, the Federal Railroad Administration conducted 34 field and compliance inspections but did not turn up any issues.

“This was a missed opportunity,” Sumwalt said.

Another oversight was not implementing Positive Train Control, a crash-oversight technology that monitors commuter trains and can stop them if they’re traveling too fast or in danger of a collision.

Sound Transit began using PTC in 2017 but experienced several glitches, delaying full implementation on 41 Sounder vehicles at a cost of $53 million until January.

All Amtrak Cascades trains have PTC installed now.

“We’re not here apportioning blame, by looking at the entire system,” Sumwalt said. “That’s how we identify deficiencies that can be corrected.”

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