Risk management failure at root of fatal train crash
Two employees killed, dozens of people injured
A collision last year in South Carolina between an Amtrak passenger train and a CSX Transportation Corporation’ freight train was caused by CSXs failure to assess and mitigate a specific risk, according to a National Transportation Safety Board (NTSB) investigation.
The incident, which killed two employees and injured 91 passengers and crewmembers, occurred on Feb. 4, when the Amtrak train was diverted from the main track through a reversed hand-throw switch into a track and collided head-on with a stationary CSX freight train.
The engineer and conductor of the Amtrak train died because of the collision. The injured were transported to medical facilities. The engineer of the stopped CSX train had exited the lead locomotive before the Amtrak train entered the track. When he saw that it was entering the track, he ran to safety and was not injured. The conductor on the CSX lead locomotive saw the Amtrak train approaching on the track 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 of operation on this segment of track was by wayside signal indications of a traffic control system. On the day prior to the accident, CSX signal personnel began upgrading signal system components to implement positive train control on the subdivision. Signal personnel ceased work for the day at 7:00 p.m., prior to completing planned work. The signal suspension remained in place resulting in the continued use of track warrants to move trains through the affected area of signal suspension.
At the time of the accident, it was dark, and the sky was cloudy.
The NTSB has determined that the probable cause of this collision of trains was the failure of the CSX Transportation Corporation to assess and mitigate the risk associated with operating through a signal suspension, which eliminated system redundancy for detecting a switch in the wrong position. The CSX Transportation Corporation conductor failed to properly reposition the switch for the main track, which allowed National Railroad Passenger Corporation (Amtrak) train P91 to be routed onto the Silica Storage track where the standing CSX train F777 was located. Contributing to the accident was the Federal Railroad Administration’s failure to implement effective regulation to mitigate the risk of misaligned switch accidents. Also contributing to the accident was National Railroad Passenger Corporation’s (Amtrak) failure to conduct a risk assessment prior to operating during a signal suspension.