Derailed and damaged equipment in this photo taken Feb. 4, 2018. Source: NTSB/Dana SanzoDerailed and damaged equipment in this photo taken Feb. 4, 2018. Source: NTSB/Dana Sanzo

The National Transportation Safety Board (NTSB) determined that a failure by Amtrak and CSX Transportation to properly assess and mitigate the risk of conducting switching operations during a signal suspension, coupled with a CSX conductor’s error, led to a fatal 2018 collision of an Amtrak train with a CSX train in South Carolina.

In addition, the NTSB faulted the Federal Railroad Administration (FRA) for its failure to implement "effective regulation" to mitigate the risk of misaligned switch accidents.

The NTSB report said the Feb. 4, 2018, accident occurred when a southbound Amtrak train shifted from the main track through a hand-thrown switch and onto a storage track where it collided head-on with a stationary CSX train. The engineer and conductor of the Amtrak train died in the collision. At least 92 passengers and crew members on the Amtrak train were taken to local hospitals.

In its report, the NTSB found Amtrak’s failure to conduct a risk assessment prior to operating during a signal suspension was also an accident cause. Although Amtrak "meets and exceeds" the FRA's safety standards to ensure safe operations of its own railroads, Amtrak trains relied only on the minimum federal safety standards when operating on host railroads. The NTSB reiterated a recommendation stemming from its investigation of a separate accident investigation in Washington state, and concluded that the passenger rail system needs to implement a safety management system on all operations, whether operating on its own tracks or on a host railroad.

In its probable cause, the NTSB stated that along with CSX Transportation’s failure to properly assess and mitigate risk, the failure of a CSX conductor to realign a switch during the signal suspension led to the collision. The NTSB also said a contributing factor in the accident was the FRA’s failure to implement effective regulation to mitigate the risk of misaligned switch accidents. The NTSB’s report said that unless the FRA implements more robust safety interventions, misaligned switch accidents will likely continue.

Accident timeline

On Feb. 4, 2018, at 2:27 a.m., southbound Amtrak train P91 was diverted from the main track through a reversed hand-throw switch onto a storage track and collided head-on with CSX local freight train F777. The accident occurred on CSX’s Florence Division, Columbia Subdivision in Cayce, South Carolina.

The engineer of the stopped CSX train had exited the lead locomotive before the Amtrak train entered the track, ran to safety and was not injured. The conductor on the CSX lead locomotive saw the Amtrak train approaching and ran to the back of the locomotive. The conductor was thrown off the locomotive and sustained minor injuries. Damage was estimated at $25.4 million.

The normal method operating this segment of track was by wayside signal indications of a traffic control system. On the day before the accident, CSX signal personnel began upgrading signal system components to implement positive train control on the subdivision. Signal personnel ended work for the day at 7:00 p.m., without completing their planned work. The signal suspension remained in place resulting in the continued use of so-called "track warrants" to move trains through the affected area of signal suspension.

Recommendations

As a result of the investigation, the NTSB issued three new safety recommendations, two of which were issued to the CSX Transportation. These recommendations address safety issues including actions and responsibilities of the train crew in handling switches. One recommendation issued to all host railroads is to work in partnership with Amtrak to implement a safety management system to assess and mitigate risks for operation on host railroads.

In addition, the NTSB reiterated four recommendations to the FRA, and one issued to Amtrak. Two recommendations to the FRA have been reclassified including one urgent safety recommendation calling on the FRA to provide instructions for railroads to follow when signal suspensions are in effect, and a switch has been reported relined for a main track.

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