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NTSB: Amtrak's lax safety culture led to crash that killed 2

Written by Michael R. Sisak/Associated Press | Nov 14, 2017 5:53 AM
amtrak1.jpg

 AP Photo/David Boe

(Philadelphia) -- Federal investigators said Tuesday they found major lapses in how Amtrak deals with safety, including more than two dozen hazardous conditions at the work zone near Philadelphia where a train slammed into a maintenance backhoe last year and killed two workers.

Chief among them, investigators said, were a foreman's failure to make sure dispatchers were still rerouting trains from the area under repair near Philadelphia and the crew's failure to use a device that would have automatically blocked trains from accessing those tracks.

"Had any of these issues been addressed, the accident may have been prevented," National Transportation Safety Board investigator Joe Gordon said at a public meeting on the crash at the agency's Washington headquarters.

The April 2016 crash killed backhoe operator Joseph Carter Jr. and supervisor Peter Adamovich. About 40 passengers on the New York to Savannah, Georgia, train were injured.

Amtrak workers told investigators that the government-owned railroad emphasized on-time performance over safety, yet plastered employee lounges with big, red signs reminding them to "think safety" and threatened to fire workers who broke certain rules.

NTSB chairman Robert Sumwalt said Amtrak's grab bag of priorities created a culture of fear and non-compliance where bending the rules seemed acceptable to "get the job done."

"Amtrak's lack of a strong safety culture is at the heart of this accident," investigator Mike Hoepf said.

Amtrak's co-chief executive officers, Richard Anderson and Charles "Wick" Moorman sent a letter to employees Tuesday updating them on steps the railroad has taken to transform its safety culture since the crash.

They include hiring a new head of safety, compliance and training, issuing alerts and advisories to remind workers of rules and an improved worker-protection training program.

"Our customers expect us to operate safely and our jobs and lives depend on it," the co-CEOs wrote. "We can and will do better. Our pledge to you is that we will do everything possible to help move us forward."

Carter's family is suing Amtrak for negligence. Their lawyer, Tom Kline, said they can only hope his death "will result in wholesale changes" in safety at Amtrak.

Toxicology reports showed that Carter, 61, had cocaine in his system, Adamovich, 59, tested positive for morphine, codeine and oxycodone and the train's engineer, Alexander Hunter, 47, tested positive for marijuana.

Only Hunter, as a train crew member, would have been subject to random drug testing at the time of the crash. In June, federal regulators expanded the testing program to include track maintenance workers. On Monday, the Federal Railroad Administration issued a rule mandating testing for opioids beginning Jan. 1.

Hunter is no longer employed by Amtrak. No amount of marijuana use by an engineer is acceptable, the railroad has said.

He told investigators that he knew of maintenance work being done in the area but was not given any warnings about equipment being on the same track as his train.

Hunter blew the train's horn and hit the brakes once he saw equipment on an adjacent track and then on his own track. Investigators say that was about 12 seconds before impact.

The train slowed from 106 mph to 100 mph at impact and only came to a complete stop about a mile down the track. The lead engine of the train derailed.

An earlier story appears below. 

(Philadelphia) -- Amtrak's safety culture suffered major lapses, including more than two dozen unsafe conditions at a work zone where a train slammed into a maintenance backhoe last year, killing two workers, federal investigators said Tuesday.

Chief among them, investigators said, were a foreman's failure to make sure dispatchers were still rerouting trains from the area under repair near Philadelphia and the crew's failure to use a device that would have automatically blocked access to those tracks.

"Had any of these issues been addressed, the accident may have been prevented or the severity mitigated," National Transportation Safety Board investigator Joe Gordon said at a public meeting on the crash at the agency's Washington headquarters.

The April 2016 crash killed backhoe operator Joseph Carter Jr. and supervisor Peter Adamovich. About 40 passengers on the New York to Savannah, Georgia, train were injured.

NTSB chairman Robert Sumwalt said Amtrak's approach to safety -- with evidence showing it prioritized on-time performance while threatening to fire workers who broke rules -- had created a culture of fear where bending the rules was acceptable to "get the job done."

"Amtrak's lack of a strong safety culture is at the heart of this accident," investigator Mike Hoepf said.
Amtrak said it would respond to the NTSB's findings later on Tuesday.

Toxicology reports showed that Carter, 61, had cocaine in his system and Adamovich, 59, tested positive for morphine, codeine and oxycodone. The train's engineer, 47-year-old Alexander Hunter, tested positive for marijuana, according to the reports.

Only Hunter, as a train crew member, would have been subject to random drug testing at the time of the crash. In June, federal regulators expanded the testing program to include track maintenance workers. On Monday, the Federal Railroad Administration issued a rule mandating testing for opioids beginning Jan. 1.

Hunter is no longer employed by Amtrak. No amount of marijuana use by an engineer is acceptable, the railroad has said.

He told investigators that he knew of maintenance work being done in the area but was not given any warnings about equipment being on the same track as his train.

Hunter blew the train's horn and hit the brakes once he saw equipment on an adjacent track and then on his own track. Investigators say that was about 12 seconds before impact.

The train slowed from 106 mph to 100 mph at impact and only came to a complete stop about a mile down the track. The lead engine of the train derailed.

An earlier story appears below. 

(Philadelphia) -- The National Transportation Safety Board is set to review the findings of an investigation into what caused a speeding Amtrak train to slam into a backhoe last year near Philadelphia, killing two maintenance workers.

The board is meeting today in Washington to determine a probable cause of the April 3, 2016 crash that killed backhoe operator Joseph Carter Jr. and supervisor Peter Adamovich.

Investigators say they've found evidence of a lax safety culture, poor communication and employee drug use at the government-owned railroad.

Investigators say the maintenance crew failed to follow safety procedures and that Amtrak management shouldn't have let work continue without detailing potential hazards.

Toxicology reports show Carter, Adamovich and the train's engineer all had drugs in their system, but a union official says that didn't play a factor.

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