Amtrak Passenger Train 501 Derailment

DuPont, Washington

December 18, 2017

Accident Report

NTSB/RAR-19/01

PB2019-100807 National 

Transportation 

Safety Board
NTSB/RAR-19/01

PB2019-100807

Notation 58913

Report Date: May 21, 2019

Railroad Accident Report

Amtrak Passenger Train 501 Derailment

DuPont, Washington

December 18, 2017

National 

Transportation 

Safety Board

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594
National Transportation Safety Board. 2019. Amtrak Passenger Train 501 Derailment, DuPont, 

Washington, December 18, 2017. NTSB/RAR-19/01.Washington, DC.

Abstract: On December 18, 2017, at 7:34 a.m. Pacific standard time, southbound Amtrak (National 

Railroad Passenger Corporation) passenger train 501, consisting of 10 passenger railcars, a power railcar, 

a baggage railcar, and a locomotive at either end, derailed from a bridge near DuPont, Washington. When 

the train derailed, it was on its first revenue service run on a single main track (Lakewood Subdivision) at 

milepost 19.86. There was one run for special guests the week before the accident. Several passenger 

railcars fell onto Interstate 5 and hit multiple highway vehicles. At the time of the accident, 77 passengers, 

5 Amtrak employees, and a Talgo, Inc., technician were on the train. Of these individuals, 3 passengers 

were killed, and 57 passengers and crewmembers were injured. Additionally, 8 individuals in highway 

vehicles were injured. The damage is estimated to be more than $25.8 million. The accident investigation 

focused on the following issues: individual agency responsibilities in preparation for inaugural service, 

multiagency participation in preparation for inaugural service, Amtrak safety on a host railroad, 

implementation of positive train control, training and qualifying operating crews, crashworthiness of the 

Talgo equipment, survival factors and emergency design of equipment, and multiagency emergency 

response. As a result of this investigation, the National Transportation Safety Board makes safety 

recommendations to the United States Secretary of Transportation, the Federal Railroad Administration, 

United States Department of Defense Fire and Emergency Services Working Group, the Washington State 

Department of Transportation, the Oregon Department of Transportation, National Railroad Passenger 

Corporation (Amtrak), and the Central Puget Sound Regional Transit Authority. The National 

Transportation Safety Board also reiterates four recommendations to the Federal Railroad Administration

and reclassifies three recommendations to the Federal Railroad Administration.

The National Transportation Safety Board (NTSB) is an independent federal agency dedicated to promoting aviation, 

railroad, highway, marine, and pipeline safety. Established in 1967, the agency is mandated by Congress through the 

Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the 

accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of 

government agencies involved in transportation. The NTSB makes public its actions and decisions through accident 

reports, safety studies, special investigation reports, safety recommendations, and statistical reviews.

The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation, 

“accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties ... and are 

not conducted for the purpose of determining the rights or liabilities of any person.” 49 C.F.R. § 831.4. Assignment 

of fault or legal liability is not relevant to the NTSB’s statutory mission to improve transportation safety by 

investigating accidents and incidents and issuing safety recommendations. In addition, statutory language prohibits 

the admission into evidence or use of any part of an NTSB report related to an accident in a civil action for damages 

resulting from a matter mentioned in the report. 49 U.S.C. § 1154(b).

For more detailed background information on this report, visit NTSB investigations website and search for NTSB 

accident ID RRD18MR001.Recent publications are available in their entirety on the Internet at NTSB website. Other 

information about available publications also may be obtained from the website or by contacting:

National Transportation Safety Board, Records Management Division, CIO-40, 490 L’Enfant Plaza, SW, 

Washington, DC 20594, (800) 877-6799 or (202) 314-6551

Copies of NTSB publications may be downloaded at no cost from the National Technical Information Service’s 

Technical Report Library at https://ntrl.ntis.gov/NTRL/. To download this publication, use product number 

PB2019-100807. For additional assistance, contact:

National Technical Information Service, 5301 Shawnee Rd., Alexandria, VA 22312, (800) 553-6847 or 

(703) 605-6000 (see NTIS website)
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Contents

Figures and Tables....................................................................................................................... iv

Acronyms and Abbreviations .................................................................................................... vii

Executive Summary ...................................................................................................................... x

1.Factual Information................................................................................................................... 1

1.1 Accident ................................................................................................................................. 1

1.2 Accident Narrative .................................................................................................................... 2

1.3 Amtrak Cascades Service.......................................................................................................... 5

1.4 Washington State Department of Transportation ..................................................................... 6

1.4.1 WSDOT Rail, Freight, and Ports Division ............................................................. 6

1.4.2 WSDOT Capital Improvements.............................................................................. 7

1.4.3 The Point Defiance Bypass Project (Lakewood Subdivision)................................ 7

1.5 Sound Transit ............................................................................................................................ 8

1.5.1 Office of System Safety and Quality Assurance..................................................... 8

1.5.2 System Safety Program Plan................................................................................... 9

1.5.3 System Safety Certification Plan ............................................................................ 9

1.5.4 Construction, Safety Certification for Point Defiance Bypass Project ................... 9

1.5.5 Hazard Analysis.................................................................................................... 10

1.5.6 Inaugural Service Point Defiance Bypass Project ................................................ 11

1.5.7 BNSF Railway ...................................................................................................... 12

1.5.8 Amtrak .................................................................................................................. 12

1.6 Operations ............................................................................................................................... 13

1.7 Oversight ............................................................................................................................... 13

1.7.1 Washington [State] Utilities and Transportation Commission............................. 13

1.7.2 Federal Railroad Administration........................................................................... 14

1.8 Personnel Information............................................................................................................. 15

1.8.1 Fitness for Duty..................................................................................................... 15

1.8.2 Training and Experience ....................................................................................... 15

1.8.3 Territory Qualification for Lakewood Subdivision .............................................. 16

1.8.4 Wayside Cues for Speed Restriction..................................................................... 18

1.8.5 Familiarity with the Siemens Charger Locomotive .............................................. 19

1.8.6 Crew Responsibilities ........................................................................................... 20

1.9 Damages Estimates................................................................................................................. 20

1.10 Equipment Information......................................................................................................... 21

1.10.1 Lead Locomotive WDTX 1402 (1)....................................................................... 22

1.10.2 Passenger Equipment ............................................................................................ 22

1.10.3 Rear Locomotive AMTK 181 (14) ....................................................................... 22

1.10.4 Predeparture Inspections....................................................................................... 22

1.10.5 Locomotive Postaccident Inspections................................................................... 23

1.11 Crashworthiness and Derailment Description ...................................................................... 23

1.11.1 Talgo Railcar Design ............................................................................................ 23
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1.11.2 Derailment Description......................................................................................... 27

1.11.3 Locomotive Crashworthiness Requirements ........................................................ 34

1.11.4 Postaccident Observations and Inspections .......................................................... 34

1.11.5 United States Passenger Railcar Crashworthiness Standards............................... 35

1.11.6 Talgo Crashworthiness Design ............................................................................. 36

1.11.7 Test and Research ................................................................................................. 41

1.11.8 Vancouver Talgo Derailment................................................................................ 41

1.12 Survival Factors .................................................................................................................... 42

1.12.1 Locomotive Survival Factors................................................................................ 42

1.12.2 Passenger Car Survival Factors ............................................................................ 43

1.12.3 Postaccident Observations of Passenger Railcar Interiors.................................... 46

1.13 Injuries ............................................................................................................................... 46

1.13.1 Locomotive ........................................................................................................... 46

1.13.2 Passenger Railcars................................................................................................. 47

1.13.3 Highway Vehicles................................................................................................. 47

1.13.4 Highway Vehicle Accident Sequence................................................................... 47

1.13.5 Passenger Ejections............................................................................................... 51

1.13.6 Occupant Space Design and Safety of Railcars.................................................... 54

1.13.7 Handicap Accessibility ......................................................................................... 56

1.13.8 Interior Glass......................................................................................................... 59

1.13.9 Emergency Egress – Lighting and Signage .......................................................... 60

1.13.10 Emergency Doors.............................................................................................. 62

1.13.11 Emergency Windows........................................................................................ 64

1.14 Emergency Response ............................................................................................................ 65

1.14.1 Pierce County Emergency Management Agency ................................................. 65

1.14.2 Fire/Rescue and EMS Response ........................................................................... 66

1.14.3 Law Enforcement Response.................................................................................. 67

1.14.4 Pierce County Incident Management Team.......................................................... 68

1.14.5 Fire Department Agencies .................................................................................... 69

1.14.6 Law Enforcement Agencies.................................................................................. 70

1.14.7 Training ................................................................................................................. 70

1.14.8 Postaccident Action............................................................................................... 71

1.15 Track and Structure ............................................................................................................... 71

1.15.1 Inspections ............................................................................................................ 72

1.15.2 Curve and Signage ................................................................................................ 72

1.16 Signal and Train Control....................................................................................................... 74

1.16.1 Positive Train Control........................................................................................... 75

2.Analysis..................................................................................................................................... 76

2.1 Introduction............................................................................................................................. 76

2.2 Inward-Facing Audio and Image Recorders........................................................................... 76

2.3 Positive Train Control............................................................................................................. 78

2.4 Human Performance ............................................................................................................... 79

2.4.1 Qualification Trips on the Territory...................................................................... 80

2.4.2 Training on the Equipment ................................................................................... 81

2.4.3 Developing Training Programs............................................................................. 82

2.4.4 Advance Warning Speed Reduction Signs ........................................................... 83
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2.4.5 Qualifying Conductor Role and Responsibilities ................................................. 85

2.5 Preparation for Inaugural Cascades Service on Bypass.......................................................... 86

2.5.1 Multiple Agency/Organization Coordination ....................................................... 86

2.5.2 Railroad System Safety Analysis.......................................................................... 87

2.5.3 Sound Transit ........................................................................................................ 88

2.5.4 Amtrak .................................................................................................................. 90

2.5.5 Safety and Security Management Plan ................................................................. 90

2.5.6 Safety Certification Process (Sound Transit Internal Oversight) ......................... 92

2.5.7 External Oversight of Sound Transit .................................................................... 94

2.6 Equipment Crashworthiness ................................................................................................... 98

2.6.1 Historical and Regulatory Approach to Crashworthiness................................... 101

2.6.2 Grandfathering .................................................................................................... 104

2.6.3 Investigative Hearing.......................................................................................... 105

2.6.4 Design Life of Talgo Series VI........................................................................... 107

2.6.5 WSDOT’s Fleet Management Plan .................................................................... 107

2.6.6 Lead Locomotive ................................................................................................ 108

2.7 Survival Factors .................................................................................................................... 109

2.7.1 Emergency Lighting............................................................................................ 109

2.7.2 Exit Controls and Manual Release Mechanism Signage .................................... 110

2.7.3 Compartmentalization......................................................................................... 111

2.7.4 Train Seat Design................................................................................................ 111

2.7.5 Passenger Ejection and Injuries .......................................................................... 114

2.7.6 Communications ................................................................................................. 118

2.7.7 Postaccident Activity .......................................................................................... 118

3.Conclusions............................................................................................................................. 120

3.1 Findings ............................................................................................................................. 120

3.2 Probable Cause...................................................................................................................... 124

4.Recommendations.................................................................................................................. 125

4.1 New Recommendations ........................................................................................................ 125

4.2 Reiterated Recommendations ............................................................................................... 128

4.3 Classified Recommendations................................................................................................ 129

Board Member Statements ...................................................................................................... 130

Appendixes................................................................................................................................. 135

Appendix A. Investigation .......................................................................................................... 135

Appendix B. DuPont Railroad of Record ................................................................................... 136

References.................................................................................................................................. 137
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Figures and Tables

Figure 1. Accident location and Point Defiance Bypass................................................................ 1

Figure 2. Aerial photograph of accident. ....................................................................................... 5

Figure 3. Sound Transit hazard risk assessment chart. ................................................................ 11

Figure 4. Location of signage on the approach to MP 19.8. ........................................................ 18

Figure 5. Side view of the Talgo trainset. .................................................................................... 23

Figure 6. Talgo passenger railcar. ................................................................................................ 24

Figure 7. Supported end of Talgo railcar. .................................................................................... 24

Figure 8. Rolling assembly cutaway and its side view. ............................................................... 25

Figure 9. Articulated connections. The image on the right side is mirrored................................ 26

Figure 10. Overhead with railcar positions labeled. .................................................................... 27

Figure 11. Detached rolling assembly from AMTK 7454 (3). ................................................... 28

Figure 12. Detached rolling assembly tower partially inside AMTK 7504(7). ........................... 29

Figure 13. AMTK 7421 (11) resting on AMTK 7424 (8). .......................................................... 30

Figure 14. Derailing path of travel of Amtrak 501. ..................................................................... 31

Figure 15. WDTX 1402 (1) postderailment position. .................................................................. 32

Figure 16. Highway vehicle struck by lead locomotive............................................................... 33

Figure 17. Siemens Charger locomotive crashworthiness features. ............................................ 34

Figure 18. Damage to WDTX 1402 (1). ...................................................................................... 35

Figure 19. Pictures of the cab design and cab damage. .............................................................. 42

Figure 20. Talgo coach class seating layout................................................................................. 44

Figure 21. Talgo business class seating layout. ........................................................................... 44

Figure 22. Coach class Americans with Disabilities Act (ADA) layout. .................................... 45
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Figure 23. Business class Americans with Disabilities Act (ADA) layout. ................................ 45

Figure 24. Final resting position of F150 and Freightliner. ........................................................ 48

Figure 25. Detached rolling assembly and Grand Cherokee. ...................................................... 49

Figure 26. Green Kia and rolling assembly on I-5. ..................................................................... 50

Figure 27. Damaged Jeep Grand Cherokee. ................................................................................ 50

Figure 28. AMTK 7421 (11) resting on AMTK 7424 (8). ......................................................... 52

Figure 29. Open end of AMTK 7421 (11). .................................................................................. 53

Figure 30. Coach class seating layout showing rotating and nonrotating seats. .......................... 54

Figure 31. Bridge railing penetrating AMTK 7423 and displaced passenger seats..................... 55

Figure 32. Child car seat near AMTK 7424 (8). ......................................................................... 56

Figure 33. Exemplar wheelchair lift and damaged lift in AMTK 7554 (4). ................................ 57

Figure 34. Photograph of missing wheelchair lift and damage to AMTK 7504 (7). ................... 57

Figure 35. Photograph of the interior lavatory damage of AMTK 7504 (7). .............................. 58

Figure 36. Jammed vestibule door, AMTK 7422 (10)................................................................. 60

Figure 37. Exemplar emergency door showing instruction placard. ........................................... 64

Figure 38. Interior emergency window removal instructions. ..................................................... 65

Figure 39. Interior emergency window removal instructions. ..................................................... 65

Figure 40. Two-mile advance warning speed sign at MP 17.8- 30 mph. .................................... 73

Figure 41. Speed restriction sign at entrance to curve MP 19.8 - 30 mph. .................................. 74

Figure 42. Railroad of record. .................................................................................................... 136

Table 1. Hazard associated with speed reductions for curves. ..................................................... 10

Table 2. Train 501 damage estimate. ........................................................................................... 21
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Table 3. Train 501 equipment information. ................................................................................. 21

Table 4. UIC-566 compared with Talgo end car design load cases. ............................................ 37

Table 5. Postaccident observations of passenger railcar interiors................................................ 46

Table 6. Breakdown of car occupant injuries............................................................................... 47

Table 7. Highway vehicle injury breakdown. [Chart incomplete pending medical records.]...... 51

Table 8. Distribution of victims to medical facilities. .................................................................. 67

Table 9. Emergency response timeline. ....................................................................................... 68
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Acronyms and Abbreviations

ADA Americans with Disabilities Act

Amtrak National Railroad Passenger Corporation

APTA American Public Transportation Association 

ARRA American Recovery and Reinvestment Act 

BLET Brotherhood of Locomotive Engineers and Trainmen

BMI body mass index

BNSF BNSF Railway

CEM crash energy management

CFR Code of Federal Regulations

CIL certifiable items list

CP control point

CSX CSX Transportation, Inc.

CTA cognitive tasks analysis

CPAP Continuous Positive Airway Pressure

CTC centralized traffic control

DOD US Department of Defense

DOT US Department of Transportation

DPU distributive power locomotive unit

ELD Electronic Logging Device

EMA Pierce County Emergency Management Agency

EO Emergency Order

FAA Federal Aviation Administration

FAST Act Fixing America’s Surface Transportation Act of 2015
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FDA US Food and Drug Administration

FMCSA Federal Motor Carrier Safety Administration

FMP fatigue management plan

FRA Federal Railroad Administration

FTA Federal Transit Administration

g gravitational force

GCOR General Code of Operating Rules

GTB General Track Bulletins

HPPL high performance photoluminescent 

HSIPR High-Speed Intercity Passenger Rail Program

I-5 US Interstate 5

IMT Incident Management Team

JBLM Joint Base Lewis-McChord

LSA lead service attendant

GPS global positioning system

MCI mass casualty incident

MHz megahertz

MP milepost

NECR New England Central Railroad

NS Norfolk Southern Corporation

OJT Amtrak’s designated on-the-job trainer

ODOT Oregon Department of Transportation

OSA obstructive sleep apnea

PA public address system

PHA preliminary hazard analysis
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PIH poison inhalation hazard

PRIIA Passenger Rail Investment and Improvement Act of 2008

PTC Positive Train Control

RPO U.S. Railway Post Office

RSAC Rail Safety Advisory Committee

SA Safety Advisory

SITP Systems Integration Test Plan

SIR Special Investigation Report

SOP Standard Operating Procedure

SMART International Association of Sheet Metal, Air, Rail, and

Transportation Workers

Sound Transit Central Puget Sound Regional Transit Authority

SSCP System Safety Certification Plan

SSMP Safety and Security Management Plan

SMS Safety Management System

SQA Safety and Quality Assurance Division

TSS track safety standard

TY&E Train, Yard & Engine

UIC International Union of Railways

UP Union Pacific Railroad

WSDOT Washington Department of Transportation

WSP Washington State Police
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Executive Summary

On December 18, 2017, at 7:34 a.m. Pacific standard time, southbound Amtrak (National 

Railroad Passenger Corporation) passenger train 501, consisting of 10 passenger railcars, a power 

railcar, a baggage railcar, and a locomotive at either end, derailed from a bridge near DuPont, 

Washington.

When the train derailed, it was on its first revenue service run on a single main track 

(Lakewood Subdivision) at milepost 19.86. There was one run for special guests the week before 

the accident. Several passenger railcars fell onto Interstate 5 and hit multiple highway vehicles. At 

the time of the accident, 77 passengers, 5 Amtrak employees, and a Talgo, Inc., technician were 

on the train. Of these individuals, 3 passengers were killed, and 57 passengers and crewmembers 

were injured. Additionally, 8 individuals in highway vehicles were injured. The damage is 

estimated to be more than $25.8 million. At the time of the accident, the temperature was 48 ̊F, 

the wind was from the south at about 9 mph, and the visibility was 10 miles in a light rain.

The following are safety issues in this accident:

• Individual agency responsibilities in preparation for inaugural service

• Multiagency participation in preparation for inaugural service

• Amtrak safety on a host railroad

• Implementation of positive train control

• Training and qualifying operating crews

• Crashworthiness of the Talgo equipment

• Survival factors and emergency design of equipment 

• Multiagency emergency response

Parties to the investigation include the Federal Railroad Administration; Washingto n 

Utilities and Transportation Commission; Amtrak; Central Puget Sound Regional Transit

Authority; Washington State Department of Transportation; Talgo, Inc.; Siemens Industry, Inc.; 

the Brotherhood of Locomotive Engineers and Trainmen; and the International Association of 

Sheet Metal, Air, Rail and Transportation Workers.

The National Transportation Safety Board determines that the probable cause of the 

Amtrak 501 derailment was Central Puget Sound Regional Transit Authority’s failure to provide 

an effective mitigation for the hazardous curve without positive train control in place, which 

allowed the Amtrak engineer to enter the 30-mph curve at too high of a speed due to his inadequate 

training on the territory and inadequate training on the newer equipment. Contributing to the 

accident was the Washington State Department of Transportation’s decision to start revenue 

service without being assured that safety certification and verification had been completed to the 
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level determined in the preliminary hazard assessment. Contributing to the severity of the accident 

was the Federal Railroad Administration’s decision to permit railcars that did not meet regulatory 

strength requirements to be used in revenue passenger service, resulting in (1) the loss of survivab le 

space and (2) the failed articulated railcar-to-railcar connections that enabled secondary collisio ns 

with the surrounding environment causing severe damage to railcar-body structures which then 

failed to provide occupant protection resulting in passenger ejections, injuries, and fatalities.
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1.Factual Information

1.1 Accident 

On December 18, 2017, at 7:34 a.m., Pacific standard time, southbound Amtrak (National 

Railroad Passenger Corporation) passenger train 501, consisting of 10 passenger railcars, a power 

railcar, a baggage railcar, and a locomotive at both ends, derailed from a highway overpass near 

DuPont, Washington. (See figure 1.)

Figure 1. Accident location and Point Defiance Bypass.

When the train derailed, it was on its first revenue service run on a single main track 

(Lakewood Subdivision) at milepost (MP) 19.86. Several passenger railcars fell onto Interstate 5 

(I-5) and hit multiple highway vehicles. At the time of the accident, 77 passengers, 5 Amtrak 

employees, and a Talgo, Inc. technician were on the train.1 Of these individuals, 3 passengers were 

killed, and 57 passengers and crewmembers were injured. Additionally, 8 individuals in highway 

vehicles were injured. The damage is estimated to be more than $25.8 million. At the time of the 

 1 Talgo, Inc., which was the original manufacturer of the passenger railcars, has the railcar service and 

maintenance contract.
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accident, the temperature was 48 ̊F, the wind was from the south at about 9 mph, the visibility was 

10 miles in a light rain.

1.2 Accident Narrative

On the morning of the accident, Amtrak’s designated on-the-job (OJT) trainer called the 

train 501 engineer to brief him on the new territory.2 They discussed the upcoming trip, includ ing 

the curve at MP 19.86. The OJT trainer suggested that the engineer slow down early and take his 

time.3

Prior to the train’s departure, the conductor, the qualifying conductor, and the engineer 

conducted a job briefing. They discussed the general track bulletins (GTB) and other items

applicable to the trip. In addition to the operating crew, there was one lead service attendant (LSA) 

and one LSA trainee. The entire crew boarded the train at its originating location, Amtrak's Holgate 

Street facility in Seattle.

Train 501 departed the Holgate Street facility at 6:09 a.m.4 It was still dark outside, and the 

weather at that time was overcast. The crew moved the train just beyond the yard to the first 

passenger stop at King Street Station MP 0.03. Train 501 departed King Street Station at 6:10 a.m. 

(scheduled departure 6:00 a.m.), 10 minutes late. Train 501 proceeded south to MP 38.2 where it 

diverged onto the Point Defiance Bypass at TR Junction MP 38.2. The train arrived at 7:13 a.m. 

(32 minutes late) at Tacoma Dome Station, MP 2.0 on the new bypass. The train departed Tacoma 

Dome Station at 7:17 a.m.

The engineer was accompanied in the cab of the locomotive by a qualifying conductor who 

was making his first trip qualifying on the physical characteristics of the territory.5 Early in the 

trip, the engineer and qualifying conductor called out wayside signals and discussed job-related

topics.6 At 6:20 a.m., the engineer told the qualifying conductor that this trip was a learning 

experience for him, including what throttle position to use to maintain speed, and that he had only 

 2 Amtrak’s title for this supervisor was road foreman of engines and his specific duties were to manage the 

on-the-job training of the employees from Amtrak’s Zone 10, which included engineers based in Seattle, Washington; 

Spokane, Washington; Shelby, Montana; and Portland, Oregon.

3 Supporting documentation referenced in this report can be found in the public docket for this accident accessible 

from the National Transportation Safety Board’s (NTSB) Accident Dockets web page by searching RRD18MR001.

4 The train was scheduled to depart at 6:00 a.m. but was delayed due to a mechanical issue. The problem was 

resolved by removing the multiple-unit cable, thereby isolating the trailing unit and having everything run from the 

head end locomotive.

5 This conductor will be referred to as the “qualifying conductor” in this report because even though he was a 

qualified conductor, he was not qualified on the Point Defiance Bypass territory. The engineer and qualifying 

conductor had not previously worked together. Conventionally, the qualified passenger train conductor was stationed 

in the train to attend to the passengers. The conductor was responsible for the overall safety of the train’s operation, 

although most decisions were made collaboratively with the engineer, the conductor was in charge of the train.

6 Amtrak had installed inward- and outward-facing audio and image recorders capable of providing recordings to 

verify train crew actions. The information in the accident narrative in this report was gathered from the crew interviews 

and the inward- and outward-facing audio and image recordings.
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operated one roundtrip over the new territory. At 6:30 a.m., rain was falling, and the train’s 

windshield wipers were operating.

For most of the trip, both the engineer and qualifying conductor remained seated, facing 

forward and looking out of the front windshield. They occasionally looked at their respective 

paperwork on the desk in front of them. The qualifying conductor filled out an unofficial Signal 

Awareness form.7 He also referenced the Central Puget Sound Regional Transit Authority (Sound 

Transit) timetable. The engineer occasionally looked down at the gauges on the operating panel. 

Throughout the trip, the engineer passed over grade crossings and appropriately sounded the bell 

and horn as required. The engineer occasionally communicated by radio with the Amtrak 

conductor who was in one of the passenger railcars. At the beginning of the trip, the qualifying 

conductor was communicating operating issues to the engineer, such as signal aspects. Later in the 

trip and nearer to the accident, the qualifying conductor and engineer conversations were about 

future trips and job assignments.

The engineer operated his train at or near track speed and saw the MP signs at MP 16 and 

MP 17. He believed that his next significant maneuver was to begin slowing the train about 1 mile 

before the curve at MP 19.86. At 7:32:07 a.m., the train passed the northbound switch into DuPont 

Yard (MP 17.7), and the engineer said out loud, “DuPont.” At 7:32:16 a.m., the train passed the 

advance speed restriction sign at MP 17.8, which was about 2 miles before the curve.

8 The engineer 

was looking forward but did not recall seeing this sign. He told investigators during his interview 

that he was not looking for that sign because it was too far in advance of the curve to be concerned 

about slowing down at that point.9

At 7:32:21 a.m., the train’s headlights reflected off the white milepost sign (MP 18). Two 

vehicle headlights were seen on a road that runs behind to the right and behind the milepost sign. 

At 7:32:26 a.m., the engineer directed his gaze to the right as the train passed that sign. The 

engineer told investigators that he was looking for the MP 18 sign but did not see it. He told 

investigators that at the time he thought he had not yet reached that location.

During the next 25 seconds, the train traveled under three I-5 cross street overpasses, the 

third one at MP 18.53. The engineer was planning to apply the train brakes about 1 mile before the 

curve when he reached the sign indicating control point (CP) 188.

At 7:32:55 a.m., the engineer briefly looked at the gauges. The signal at CP 188 was visible 

ahead and was green (clear). A silver signal bungalow could be seen to the right of the signal. The 

CP sign (1876) was washed out by the reflection of the headlight in the silver signal bungalow. 

Investigators noted that 3 seconds later, the CP 1876 sign was detectable as a white rectangle in 

front of the signal bungalow. However, the markings appeared washed out and difficult to discern, 

 7 The Signal Awareness form had not yet been vetted and thus was not finalized. 

8 The advance speed restriction sign is also referred to as the ‘advance warning board.’

9 Sound Transit used BNSF Railroad’s (BNSF) standard for speed reduction signs which are placed 2 miles before

the speed restriction. The 2-mile reduction is based on the notice necessary for slowing freight trains. Passenger trains 

slow more quickly when the brakes are applied and do not have to start reducing speed until much closer to the 

restriction.
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even as the train passed the sign. During this time the qualifying conductor was looking out the 

front windshield.

At 7:33:06 a.m., the sign for MP 19 was visible. The engineer asked the qualifying 

conductor about his return trip to Seattle. Three seconds later the qualifying conductor began to 

reply to him, and the train passed the MP 19 sign at 7:33:10 a.m. At 7:33:12, just over 1/2 mile 

from the curve, the intermediate signal at MP 19.8 first came into view.

As the qualifying conductor was responding to the engineer’s question, a series of three 

double “beeps” were recorded in the cab of the locomotive at 7:33:20 a.m. The engineer 

immediately made a minimum brake application. A warning light (consistent with overspeed 

traction lockout) illuminated on two screens on the engineer’s control panel. On the left screen, 

flashing text and an illuminated warning appeared. On the right screen, an illuminated warning 

appeared underneath the speedometer. After the beeping started, the engineer looked to his left 

and then moved the automatic brake handle forward slightly. The conversation between the two 

crewmembers continued during this time, with the engineer looking left toward the qualifying 

conductor and asking him another question. The qualifying conductor gave a brief reply, then the 

conversation paused. The engineer looked to his right at the display, looked forward again for 

1 second, back to the right at the display for another 2 seconds, then looked forward. He then 

looked at the left display and said, “I guess that happens when...” The conversation paused again 

as the engineer looked down at the desk to his left. He then looked to his right, and back forward 

again.

At 7:33:34 a.m., the concrete structural walls were visible on both sides of the track leading 

up to the Mounts Road overpass near MP 19.5. The 30-mph speed restriction sign at the entry to 

the curve at MP 19.75 was visible. 

At 7:33:38 a.m., the engineer looked to the right and back forward again. Three seconds 

later he leaned forward and said, “We just tripped the overspeed.” (The engineer told investigators 

that he was unfamiliar with the alarm for an overspeed on this new locomotive. He said it was not 

covered during his training and he had not experienced it the few times he had operated the 

locomotive.) The qualifying conductor was also looking forward.10 The engineer then pushed the 

automatic brake handle forward to the “Handle Off” position and looked down at the automatic 

brake handle.11 He removed his hand from the automatic brake handle, reached for the independent 

brake handle, and then back to the automatic brake handle.

The engineer told investigators that he had seen the signal at MP 19.8 and initially thought 

that they were at CP 188.12 A moment later, he saw the 30-mph speed restriction sign and realized 

that they were nearing the entrance of the curve. At 7:33:44 a.m., he called out an expletive, and 3

seconds later said, “We’re dead.” The train speed decreased from 83 mph to 78 mph as the train 

 10 The qualifying conductor told investigators that the speedometer on the conductor’s side of the locomotive, 

after a period of time, goes blank. It can be re-illuminated by pressing a button. However, the conductor stated that he 

did not re-illuminate the screen because he was focused on the physical characteristics of the territory and referencing 

his General Track Bulletins.

11 The “Handle Off” position slowly reduces the brake pipe pressure to 0 psi at a full-service brake rate.

12 The Brotherhood of Locomotive Engineers and Trainmen (BLET) local chairman told investigators, “CP188 

actually looked like – there are some similarities to the signal that was at the curve.”
NTSB Railroad Accident Report

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entered the left-hand curve at MP 19.8 where the 30-mph speed took effect. The engineer did not 

make an emergency brake application before the accident. 

About 7:34 a.m., the lead locomotive and the following seven coaches derailed, the 

locomotive and several coaches careened down a wooded embankment, some reaching and 

blocking the southbound lanes of I-5. Two coaches came to rest on the overpass and several cars 

went down the embankment to the left of the overpass while the trailing unit (AMTK 181) 

remained on the rail just short of the overpass.

Figure 2. Aerial photograph of accident. (Photo provided by Washington State Police [WSP].)

During the postaccident interview, the engineer was asked if he had any thoughts about 

why he did not see the two wayside signs he was looking for at MP 18 and CP 188. The engineer 

stated:

The only thing I can think of is the locomotive has different visibility from the front 

and the gauges take your eyes off the window. In thinking about it, the only thing I 

can think of is that I was possibly quickly looking at a gauge or something and 

missing the sign. That’s my best – you know, I don’t know.

The engineer also told investigators that he was aware of the curve at MP 19.8, and its 

30-mph speed restriction. He stated, “I knew the curve was there. I was planning for the curve. It 

wasn’t like I forgot it was there.”

1.3 Amtrak Cascades Service

Train 501 was part of the Amtrak Cascades brand. This was a train service that initially 

operated between Seattle and Portland. After several trial operations dating back to 1994, the full 
NTSB Railroad Accident Report

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Cascades brand was rolled out on January 12, 1999. Amtrak extended a second train to Eugene, 

Oregon, in late 2000.

On October 1, 2013, the federal government shifted responsibility for funding the Amtrak

Cascades services to states served, in accordance with the Passenger Rail Investment and 

Improvement Act (PRIIA) of 2008. The Amtrak Cascades system became a joint program of 

Washington State Department of Transportation (WSDOT) and the Oregon Department of 

Transportation (ODOT). Before this, Amtrak had contributed a portion of funding for the service. 

As a result, WSDOT and ODOT contracted with Amtrak to operate the Amtrak Cascades service. 

Since Amtrak no longer contributes financially to the operating costs, the service is now funded 

by ticket revenues and state funds. 

Annually, the Amtrak Cascades service currently operates more than 4,000 departures and 

serves more than 810,000 passengers. Its trains, operating in the Pacific Northwest each day offer:

• Four daily round trips between Seattle and Portland (scheduled to increase to 6 trips 

with the return to the Point Defiance Bypass)

• Two daily round trips between Seattle and Vancouver, British Columbia

• Two daily round trips between Portland and Eugene, Oregon

1.4 Washington State Department of Transportation

WSDOT is a cabinet-level agency reporting to the governor and headed by the Washingto n 

secretary of transportation. In addition to building, maintaining, and operating the state highway 

system, WSDOT is responsible for administering the state ferry system; and working in 

partnership with others to maintain and improve local roads, railroads, and airports; as well as 

supporting alternatives to driving, such as public transportation, bicycles, and pedestrian programs.

1.4.1 WSDOT Rail, Freight, and Ports Division

Within the WSDOT, there is a Rail, Freight, and Ports division specifically responsible for 

managing grants, funding, and delivering capital improvements. The division has planning 

responsibilities for Washington’s rail, freight, and port programs. The division also oversees the 

management of the Amtrak Cascades intercity passenger rail service along the Pacific Northwest 

Rail Corridor.

13

As stewards of the Amtrak Cascades system, WSDOT is responsible for reporting; 

budgeting; performance tracking; construction project grant administration or management; local, 

regional, state, and national program coordination; working with the freight rail partners that own 

the railroad tracks; public outreach; and marketing activities.

 13 The Pacific Northwest Rail Corridor is 1 of 11 of the United States Department of Transportation (USDOT) 

officially designated high-speed rail corridors in the United States.
NTSB Railroad Accident Report

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1.4.2 WSDOT Capital Improvements

In 2006, WSDOT developed its long-range plan for Amtrak Cascades that projected 13 

roundtrips between Portland, Oregon, and Seattle, Washington, and 4 trips between Seattle, 

Washington, and Vancouver, British Columbia. WSDOT applied for and received federal 

American Recovery and Reinvestment Act (ARRA) grants in 2009-2010 to undertake the first set 

of improvements outlined in the plan. After being awarded nearly $800 million in funding, 

WSDOT began 20 rail infrastructure projects, including:

• Station upgrades and construction

• Track and signal upgrades

• New tracks, ties, and sidings

• New locomotives

• Landslide mitigation work

By the 2017 deadline, delivery of the 20 projects and service outcome agreements with 

Amtrak, BNSF Railway (BNSF), and Sound Transit were completed. On-time reliability increased

to 88 percent, travel times between Seattle and Portland decreased by 10 minutes, and two more 

round trips were added between Seattle and Portland (for a total of six).

1.4.3 The Point Defiance Bypass Project (Lakewood Subdivision)

The Point Defiance Bypass project, initiated in late 2014, was the final project completed 

by Sound Transit using federal grants. The project included track improvements and a new Amtrak 

Cascades station in Tacoma. About $180 million was invested in improvements to the Point 

Defiance Bypass project.

Sound Transit was a contractor for WSDOT on this project. Sound Transit, hired and 

managed contractors which undertook the work. All improvements are owned by Sound Transit 

that is responsible for track operation and maintenance of the Point Defiance Bypass. BNSF is 

responsible for dispatching trains in the corridor. WSDOT directly contracted for and managed the 

work to build the new Tacoma Dome station.

Improvements on the Point Defiance Bypass included new and upgraded tracks, ties, and 

ballast on the 14.5-mile route; five reconstructed at-grade crossings, each with advanced warning 

and signal systems; four railroad bridge rehabilitations/reconstructions; and a second platform at 

the Tacoma station. Safety improvements provided in the project included:

• New traffic signals to coordinate with the train signals and railroad crossing gates to 

minimize queuing and keep traffic moving

• Median barriers to prevent vehicles from going around the railroad crossing gates
NTSB Railroad Accident Report

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• New signage to alert vehicles to not stop on the tracks

• Sidewalks to provide Americans with Disabilities Act (ADA) accessible routes over 

the tracks in locations where sidewalks are present

• Wayside grade crossing horns to minimize noise outside of the intersection, so trains 

do not have to blow horns when approaching the intersection

• Fencing along both sides of the tracks to discourage trespassing

Sound Transit built a new double-track concrete trestle east of Freighthouse Square to 

increase capacity for passenger rail service in the corridor. WSDOT provided some funds to 

support a new Tacoma Trestle project. In addition, a second platform was built at the station to 

accommodate both Amtrak Cascades and Sounder trains. An extension was also added to the 

existing platform to accommodate Amtrak long-distance trains. WSDOT funded these 

improvements through a contract with Sound Transit, which managed the construction and is 

responsible for the ongoing maintenance.

1.5 Sound Transit

Sound Transit is a regional transit authority for the urban areas of King, Pierce, and 

Snohomish counties. Sound Transit plans, builds, and operates express bus, light rail, and 

commuter train services.

1.5.1 Office of System Safety and Quality Assurance

The Safety and Quality Assurance Division (SQA) is led by the chief safety and quality 

assurance officer, who is responsible for the development and implementation of safety programs 

and initiatives and is a direct report to Sound Transit’s chief executive officer. Within the SQA the 

following directors oversee the following functions:

• Transit safety system director: Manages the functions of employee health and safety, 

safety management system (SMS) implementation, transit safety, transit safety system 

outreach and the Division’s document control

• Construction and systems safety director: Manages the agency safety certificatio n 

program and the construction safety monitoring and oversight for all capital projects

• Quality assurance director: Develops and manages agency quality requirements and 

provides oversight to ensure quality requirements are consistently implemented, 

monitored, and improved to meet agency and Federal Transit Administration (FTA) 

expectations for capital projects. The quality assurance director also develops and 

implements the agency’s Safety Audit program to ensure compliance with regulatory 

safety requirements including the FTA, the State of Washington’s safety oversight, the 

Federal Railroad Administration (FRA), and the American Public Transportatio n 

Association (APTA)
NTSB Railroad Accident Report

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1.5.2 System Safety Program Plan

The Sound Transit’s System Safety Program Plan (SSPP) provides an overview and outline 

of the safety program elements applicable to Sounder Commuter Rail. Each program element is 

further defined and supported by respective departmental procedures, manuals and other 

documentation as applicable. Sound Transit developed its SSPP using the American Public 

Transportation Association Manual for the Development of System Safety Program Plans for 

Commuter Railroads (APTA Manual) as guidance. The APTA Manual reflects the industry and 

FRA guidance on system safety program plans and is the current resource for developing system 

safety plans for commuter rail.

1.5.3 System Safety Certification Plan

Sound Transit’s System Safety Certification Plan (SSCP) is intended to ensure that all 

facilities, systems equipment, procedures and plans, training programs, and emergency 

preparedness programs are reviewed for compliance with safety requirements by SQA in 

coordination with the Operations Department and Design Engineering and Construction 

Management Department. The chief safety and quality assurance officer is responsible to certify 

compliance through a Safety Certification Verification Report, prior to revenue service.

Sound Transit’s Safety and Security Management Plan (SSMP) identifies plans, 

management structure, responsibilities, and authority for documentation, confirmation, activities, 

and tasks necessary to integrate safety and security into each phase of Sound Transit’s capital 

projects. The SSMP describes the integration of safety and security activities, including methods 

for identifying, evaluating, mitigating, and resolving safety hazards and security vulnerabilities. 

According to Sound Transit, the SSMP is designed to do the following:

• Documents Sound Transit's commitment and philosophy to achieve the highest 

practical level of safety and security for customers, employees, contractors, and the 

public

• Describes safety and security processes and activities that minimize risk of injury and 

property damage

• Integrates safety and security functions and activities throughout Sound Transit’s 

organizational and reporting structure

1.5.4 Construction, Safety Certification for Point Defiance Bypass Project

Sound Transit contracted the construction of improvements to the Lakewood Subdivisio n 

to accommodate the re-routing of Amtrak service (including WSDOT’s sponsored Cascades

service) through Sound Transit’s Lakewood Subdivision. This relationship with WSDOT is 

reflected in the High Speed Intercity Passenger Rail Program Amended and Restated Construction 

and Maintenance Agreement (RRB-1043), dated June 30, 2016, as amended; and the Service 

Outcomes Agreement among WSDOT, Amtrak, and Sound Transit (RRB-1044), dated October 1, 

2014. However, the operation of Amtrak trains through the Lakeview Subdivision is under an

Operating Agreement between Amtrak and Sound Transit, dated January 1, 2015.
NTSB Railroad Accident Report

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Sound Transit completed safety certification in accordance with the 2015 Sound Transit 

SSMP. The SSMP required the testing, verification, and documentation of static and dynamic 

testing of installed systems, signage, and clearances. Sound Transit conducted oversight, provided 

field staff during testing, and required contractor documentation to verify the testing and 

commissioning of installed equipment in accordance with relevant contract specifications. Grade 

crossing warning times were verified during multiple incremental train speed testing events. Once 

right of way tests, signal, and grade-crossings were completed and verified, Sound Transit 

management certified through a Safety Certification Verification Report that the Point Defiance 

Bypass project was ready to be transitioned to operations. This would allow for WSDOT and 

Amtrak to begin prerevenue testing. After prerevenue testing began, Sound Transit did not receive 

any reports of issues, deficiencies, or anomalies with the operating system, right of way or grade

crossings from Amtrak.

1.5.5 Hazard Analysis

As part of the 2015 Sound Transit SSMP, Sound Transit developed a Point Defiance 

Preliminary Hazard Analysis (PHA) dated April 24, 2015. Included in this analysis, the hazard 

associated with speed reductions for curves was identified and the hazard was addressed as shown 

in table 1.

Table 1. Hazard associated with speed reductions for curves.

Location Track curves

Hazard Derailment

Potential Cause Train speed not within specified limits at track curves

Effect Consequence Potential derailment, equipment damage, major/minor injuries

Initial Risk 1C – Unacceptable

Existing Mitigation 

Measure

Timetable

Recommended 

Mitigation Measures 1. Ensure curves; elevation and speed limitations are designed according to Title 49 Code 

of Federal Regulations (CFR) 213.57 

2. Develop inspection and maintenance procedures according to 49 CFR 213.233 Track 

Inspection 

3. Future positive train control (PTC)

Suggested 

Resolution (Safety 

verification)

1. PTC regulated speeds according to timetables

2. Standard operating procedures

Residual Risks 1D – Undesirable

Remarks and 

Comments Requires safety certification verification during integrated testing, commissioning, and 

operational phases. 

Figure 3 includes the Hazard Risk Indices table used to determine the risk associated with 

identified hazards. Sound Transit staff are required to use this table as a tool to identify the risk 

associated with a hazard and then mitigate accordingly to the risk decision matrix to reduce or 

eliminate the hazard. Hazards that fall into the “Unacceptable” category require mitigations and 

are otherwise not acceptable. Hazards falling into the “Undesirable” category are allowed to exist 

with the approval and signoff of the “Executive Leadership Team Representatives (ELTR)” or 
NTSB Railroad Accident Report

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“Senior Oversight Approval Panel (SOAP).”14

Figure 3. Sound Transit hazard risk assessment chart.

1.5.6 Inaugural Service Point Defiance Bypass Project

National Transportation Safety Board (NTSB) investigators learned that WSDOT and 

Sound Transit representatives had several meetings to discuss a start date for service. According 

to WSDOT officials, on September 28, 2017, Sound Transit provided WSDOT with a starting date 

of December 18, 2017, to begin the inaugural service. Amtrak did not object to the date. Once 

 14 The Sound Transit senior director of Safety and Quality Assurance (chief safety officer) is the chair of the 

SOAP and a member of the ELTR Safety and Security Design Construction Committee (SSDCC).
NTSB Railroad Accident Report

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decided, Sound Transit, Amtrak, and BNSF proceeded in the preparation to operate on the new 

route. 

On the date that the inaugural service began, the Lakewood Subdivision improvements 

were completed except for the positive train control (PTC) portion of the project which was 

required to mitigate overspeed derailments on track curves. This change should have required a 

change to the PHA document, however the PHA was never updated to reflect the absence of the 

designated hazard mitigation. Sound Transit turned the project over for revenue service with 

minimal controlling mitigations (standard operating procedures [SOP]) for the hazard of a 

derailment on curves. The final safety and security verification matrix included the same 

mitigations that were provided in the PHA; however, the timetable had also been added as a 

controlling mitigation. Using the hazard risk indices, Sound Transit assigned risks to the hazard as 

shown above. The initial risk for the curve hazards was “1C – Unacceptable” and the residual risk 

was “1D – Undesirable.” In either case, before trains were operated, Sound Transit’s system safety 

program required “Safety certification verification during integrated testing, commissioning, and 

operational phases.” As previously noted, Sound Transit’s SSMP references “procedures and 

training” as the lowest protective mitigation. On the day of the accident, the status of this hazard 

was marked as “Completed Accepted,” even though PTC had not been implemented, which was 

the mitigating measure to eliminate the hazard.

1.5.7 BNSF Railway

Sound Transit contracted BNSF to provide the operating crews to operate their Sounder 

commuter operations. Further, they contracted BNSF to provide the train dispatching for the 

Lakewood Subdivision (Point Defiance Bypass). BNSF also prepared the timetable describing the 

Lakewood Subdivision. The timetable contained specific instructions to the operating crews 

pertaining to this section of railroad, including speed tables and the location of the accident curve.

BNSF included the Lakewood Subdivision on its PTC Implementation Plan filing with the FRA 

to accelerate Sound Transit’s PTC installation. The FRA approved BNSF’s revised PTC 

Implementation Plan on March 6, 2018.

1.5.8 Amtrak

WSDOT contracted Amtrak to provide the operating crews and to maintain the equipment 

for the Cascades Service. Amtrak was required to provide qualified and trained operating and 

mechanical employees. Further, Amtrak had to provide the necessary supervision and 

recordkeeping that is required by the FRA. Amtrak attended some but not all the meetings 

preparing for the new service on the Point Defiance Bypass. (Preparing the operating crews for the 

new route is covered in section 2.5 of this report.)

The Amtrak locomotive supervisors explained to NTSB investigators that they had noticed 

that the timetable did not require the conductor to remind the engineer by radio of the upcoming 

speed restriction at MP 19.8 like other locations with a major required reduction in speed. (See 

section 2.5.2 in this report for further discussion on the requirements of the Fixing America’s 

Surface Transportation Act of 2015 (FAST Act) and FRA Emergency Order 29.) The Amtrak 

assistant superintendent told investigators that the plan was to update Amtrak’s Speed Limit 
NTSB Railroad Accident Report

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Reduction Action Plan through a General Order that would be issued implementing a “crew focus 

zone” at MP 19.8 on the new Lakewood Subdivision. This was to be completed in January several 

weeks after revenue service on the subdivision had begun. According to the assistant 

superintendent, this is the responsibility of the Amtrak Pacific Northwest Division and was 

overlooked prior to initiating service.15

1.6 Operations

The Lakewood Subdivision was owned and maintained by Sound Transit extending from 

TR Junction (MP 0.7) in Tacoma to BNSF’s Nisqually Junction (MP 21.3). Sound Transit’s 

commuter service operated between Lakewood (MP 10.1) and Seattle, Washington, and was 

contracted with BNSF to provide crews to operate the trains.16 Amtrak, through contract with 

WSDOT, provided Cascades services along the entirety of the subdivision. Tacoma Rail operated

on the southern portion of the subdivision between Nisqually Junction and Lakewood providing 

switching service to freight customers.

17 Tacoma Rail did not operate north of Lakewood.

Occasionally, there was BNSF freight service to JBLM at the southern end of the subdivision.

The operating crews were governed by the 7th edition of the General Code of Operating 

Rules effective April 1, 2015. Specific instructions relating to the subdivision were found in the 

Sounder Commuter Rail Timetable No. 2, effective November 13, 2017 (Since BNSF provided 

the operating crews to operate the Sound Transit commuter trains and train dispatching services,

BNSF also prepared the Timetable for the territory.) Modifications to the timetable and additional 

instructions were issued by General Orders – Sounder Commuter Rail Division. Also, each train 

(either Sound Transit, Amtrak, Tacoma Rail, or BNSF) that operated on the subdivision received 

a track warrant and bulletins specific to that train and that day of operation. Further, Amtrak train 

crews were governed by General Orders titled, Amtrak Pacific Northwest Division.18

1.7 Oversight

1.7.1 Washington [State] Utilities and Transportation Commission

The Railroad Safety Section of the Washington [State] Utilities and Transportatio n 

Commission (WUTC) ensures public safety by monitoring operations of the 25 railroad companies 

offering service in Washington. The section conducts safety inspections of various aspects of 

railroad operations. Under state authority, staff inspect crossings and walkways and evaluate, 

investigate, and recommend to the commission whether company filed petitions related to crossing 

changes and close clearances should be approved. Working with the FRA, commission staff 

conduct inspections of company operating practices, hazardous materials handling, crossing 

 15 The Amtrak Pacific Northwest Division is based in Seattle and responsible for train operations in the 

Northwestern United States.

16 BNSF train crews operate Sound Transit commuter trains from Seattle to Lakewood. Currently, there is no 

Sound Transit service south of Lakewood.

17 Tacoma Rail is a local Short Line railroad.

18 Supporting documentation can be found in the public docket for the NTSB investigative hearing, “Managing 

Safety on Passenger Railroads,” July 10 – 11, 2018, accessible from the NTSB Accident Dockets web page by 

searching DCA18HR001.
NTSB Railroad Accident Report

14

signals and track. The section also provides education and outreach services as part of the 

Operation Lifesaver program. It also investigates accidents and complaints from the public and 

partners with local, state, and federal agencies to implement safety awareness and improvement 

programs.

1.7.2 Federal Railroad Administration

The FRA and the WSDOT were responsible for providing oversight of some elements of 

the Point Defiance Bypass Project and Sound Transit (subgrantee). Most of these elements are 

financial in nature, however, both agencies had a responsibility for ensuring that the project would 

be safe to operate. The terminology “safe to operate” is ambiguous. In its contract with Sound 

Transit for the construction and completion of the project, WSDOT required Sound Transit to 

complete a Safety Security Certification Verification Report to certify that the project was “safe 

and ready for use in revenue operations.”19 Although WSDOT used staff to ensure that the project 

was proceeding along according to schedule and budget, the role as it related to overseeing safety 

was limited. WSDOT had a staff member participate in Sound Transit’s PHA activities and some 

testing, including grade crossing testing and validation. However, WSDOT did not have a 

formalized approach to oversee Sound Transit’s implementation of its safety certification process. 

There was not a formal requirement for WSDOT to oversee safety activities of the subgrantee.

To meet the requirements of the federal funding mechanism, the FRA required submissio n 

of design plans, proposed expenditures, construction bids, and other formal documents that 

supported High-Speed Intercity Passenger Rail Program (HSIPR Program) funding requests under 

the American Recovery and Reinvestment Act of 2009 (ARRA). The FRA provided written 

approvals to WSDOT and other entities that included approvals for preliminary engineering, final 

design implementation, and construction stages for the bypass. The FRA also required that 

WSDOT submit a System Safety Program Plan, and because the project was being constructed by 

Sound Transit, Sound Transit’s Safety and Security Management Plan would apply. Although 

these documents are sent to the FRA for review and guidance, if applicable, the FRA does not 

approve the plans. 

The FRA’s role for providing oversight is split between grant oversight and safety 

oversight. The policies and procedures as outlined in the grantee’s or subgrantee’s Safety and 

Security Management Plan (SSMP) governing the safety processes to be followed during project 

design, construction, and prerevenue testing are simply grant requirements. The FRA Passenger 

Rail Division provides guidance and feedback on these safety documents, but the FRA has no 

regulatory authority to approve or require changes to an SSMP or the SSMP’s implementation. In 

addition to providing guidance, the FRA Office of Safety, including the Passenger Rail Divisio n,

will in some instances perform site visits and observe prerevenue activities. In the case of the Point 

Defiance Bypass, the Passenger Rail Division did review Sound Transit’s hazard management 

program but only in respect to its meeting a deliverable of the grant.

There were 34 field and compliance inspections conducted by the FRA regional office prior 

to the initiation of revenue service, these inspections included track, signal, operating practices, 

 19 Safety Security Certification Verification Report (SSCVR) for Point Defiance Bypass Track & Signal 

Improvement Project, October 27, 2017. 
NTSB Railroad Accident Report

15

grade crossings, and motive power and equipment. However, safety certification was not in the 

scope of these inspections.

1.8 Personnel Information

1.8.1 Fitness for Duty

Both the 55-year-old engineer and the 48-year-old qualifying conductor had slept the night 

before going on duty the day of the accident. They both scheduled their sleep to be prepared for 

the upcoming shift. They both stated that they felt rested for the trip.

The engineer had been diagnosed with obstructive sleep apnea (OSA) which was being 

treated with a continuous positive airway pressure (CPAP) machine.20 He was also being 

effectively treated for type 2 diabetes, hypertension, and high cholesterol. The qualifying 

conductor did not have any medical issues.

Following the accident, the engineer, conductor, and qualifying conductor on the Amtrak 

train underwent NTSB requested postaccident toxicological testing.

21 Both had evidence of 

medications used during their emergency treatment. In addition, the engineer had a trace amount 

of diphenhydramine and some naproxen in his system.

22 At the levels detected, neither would have 

been considered impairing. All other crewmembers tested negative for illicit drugs and alcohol.

1.8.2 Training and Experience

The engineer of train 501 was hired by Amtrak on May 17, 2004. He worked as a conductor 

for several years in the Pacific Northwest. Specifically, he worked out of Seattle and in Vancouver, 

British Columbia, as far east as Minot, North Dakota, and south to Portland, Oregon. He became 

a certified engineer in August 26, 2013, and worked mainly out of Portland (as far as Pasco to the 

east, Seattle to the north, and Klamath Falls to the south). The Amtrak road foreman of engines

OJT told investigators that the engineer was very competent and conscientious, and he had no 

reservations about him. The assistant superintendent, road operations said that the engineer was 

safe and aware of what was going on.

The Amtrak qualifying conductor was hired by Amtrak June 15, 2010, in Seattle, 

Washington. He went to Amtrak’s training facility in Wilmington, Delaware, where he spent 

8 weeks as part of their new hire training. Afterwards, he returned to Seattle, and participated in 

 20 A portable CPAP machine was among his personal items recovered from the locomotive. NTSB Research and 

Engineering verified use of the device with downloaded data.

21 Testing was performed by the Federal Aviation Administration’s (FAA) Bioaeronautical Sciences Research 

Laboratory and included more than 1,300 substances. Further, this testing was voluntary because it exceeded the 

mandatory FRA testing which only tests for a limited number of substances. 22 Diphenhydramine is a sedating antihistamine available over the counter in a wide variety of products such as 

Benadryl and Unisom. It is used to treat cold and allergy symptoms and is also commonly the active ingredient in 

nonprescription sleep aids. Diphenhydramine carries the following warning: may impair mental and/or physical ability 

required for the performance of potentially hazardous tasks (such as driving, operating heavy machinery). Altered 

mood and impaired cognitive and psychomotor performance may also be observed. Naproxen is an over the counter 

anti-inflammatory pain medication often marketed with the name Aleve. It is not generally considered impairing.
NTSB Railroad Accident Report

16

on-the-job training for conductors. He became a qualified conductor on October 18, 2011. He was 

qualified to work out of Seattle to Portland, Spokane, and Vancouver, British Columbia. On the 

day of the accident, he was riding on the head-end of the train during his first trip qualifying on 

the Lakewood Subdivision and requalifying on the BNSF Seattle Subdivision.

The Amtrak conductor was hired on June 6, 2014, and promoted to conductor on 

October 28, 2015. At the time of the accident he was working as the conductor and located in one 

of the passenger railcars. There were no assistant conductors in the other passenger railcars.

1.8.3 Territory Qualification for Lakewood Subdivision

The Amtrak road foreman of engines OJT told NTSB investigators that the new territory 

“is not very challenging” because it was straight, mainline track with relatively few signals and 

crossings. He considered it less challenging than the territory between Tacoma and Seattle. This 

was also the general consensus of other Amtrak officials interviewed.

Amtrak’s assistant superintendent (road operations), the road foreman of engines OJT from 

Portland, Oregon, and the road foreman of engines from Seattle, Washington, were among those 

that determined what training was appropriate for qualifying engineers and conductors on the 

physical characteristics of new territory.23 They agreed that, given the length of the route, each 

engineer needed to take multiple observational trips over the territory (to physically see the 

territory and review the track charts and timetable), and was required to operate the train for at 

least one roundtrip over the territory. The assistant superintendent, road operations told 

investigators that the feedback they received from the FRA during the qualification process was 

positive.

Qualification on the new territory for engineers started on November 27, 2017. The 

qualification elements included operating a train and observational rides from the head-end and 

rear-end of locomotives. The qualifying period for all crewmembers lasted about 10 days. All 

observational rides were performed at night. The number of trainees in the operating compartment 

varied each trip but reached as many as seven people. After several observational rides, the 

engineers then operated the train over the territory under the supervision of a qualified foreman. 

According to Amtrak’s assistant superintendent of road operations, every engineer was given as 

many trips as the qualifying road foreman felt was needed, and most were completed within one 

to two roundtrips and several trips of observation. Engineers who the road foreman believed 

needed additional time to qualify were brought back at a later date to operate the trains on the new 

territory.

A Brotherhood of Locomotive Engineers and Trainmen (BLET) local chairman was also 

involved in the initial training and qualification process and concurred with the qualification plans. 

He believed that the route was “a relatively simple piece of railroad” but realized that crews had 

to be careful going downhill towards the accident curve. He told investigators, “[The physical 

 23 Amtrak’s assistant superintendent, road operations was involved in the testing and qualifications of the 

engineers and conductors operating over the new territory. The road foreman of engines OJT (from Portland), in 

addition to having local responsibilities, covered a large part of Amtrak’s Northwest region in charge of the on-the-job 

training of the locomotive engineers.
NTSB Railroad Accident Report

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characteristics training] was adequate for me. But...in a perfect world, we would have been out 

there, you know, twice as long...if we could have had more exposure, all kinds of day.”

The train 501 engineer made between 7 and 10 observational rides over the territory before 

operating the train over the territory under the supervision of a road foreman. He had operated the 

train twice northbound, and one time southbound, that included transiting the curve at MP 19.8. 

All the trips were made at night. After his last trip, the road foreman indicated that he did not 

believe the engineer required additional time operating the train to become qualified, and the 

engineer concurred.

Following their qualifying trips, engineers were given a final qualifying physical 

characteristics examination consisting of 12 fill-in-the blank questions. The examination was 

prepared by the local Amtrak supervisors based on a consensus of “what they believed” was 

important to know on the new route. The train 501 engineer took this examination on December 16, 

2017, and achieved a score of 100 percent. The last question on the exam referenced the curve at 

MP 19.8:

Traveling southward what is the permanent speed restriction for Talgo and 

passenger trains at MP 19.8 and is the 1.6% grade ascending or descending? (The 

answer was 30 mph and a descending grade).

The assistant superintendent, road operations stated that the greatest challenges in the last 

year was not having the new route available to Amtrak until they were close to starting passenger 

service. He told investigators: “If we could have had another, you know, couple of months to get 

that done, it would have been great... Having new service, new route and new locomotives all at 

one time made it a bit difficult as well.”

However, he did not believe that there was a need to provide additional observation rides 

or time spent operating the train over the new territory.

The Amtrak road foreman of engines OJT told investigators:

I felt they (the qualifying engineers) had enough exposure to the territory where 

they could run it safely as long as they were being mindful of their limitations, and 

if they felt less comfortable than others might, that they would run slower or be 

more cautious... I was not concerned anyone out there couldn’t have operated over 

that track safely.

Conductors qualifying on the territory typically made observational rides from either the 

trailing locomotive or on one of the passenger railcars, and not the head-end of the locomotive. 

The conductor on train 501 made about five roundtrip observational rides on the Lakewood 

Subdivision. Conductors were also required to pass a final qualifying physical characteristics 

examination (which was different than the one administered to the engineers).
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1.8.4 Wayside Cues for Speed Restriction

NTSB investigators were able to identify the advanced warning board sign at MP 17.8 

while watching the outward-facing video. The BLET local chairman told investigators, “We don’t 

normally use the advanced board, but you got to...especially in a new territory.” Amtrak’s road 

foreman of engines OJT told investigators, “An advanced speed board doesn’t really have any 

effect on their operation because it’s just too far out...to be of any use to them for braking for a 

curve 2 miles away.” He added that some engineers may opt to brake earlier than 1 mile from the 

curve because of the downhill grade and the need to reduce the train’s speed from 79 mph to 30 

mph as they approach the curve. (See figure 4.)

Figure 4. Location of signage on the approach to MP 19.8.

NTSB investigators also viewed the locomotive’s outward-facing video to assess the 

conspicuity of the wayside signs at MP 18 and CP 188. Investigators noted that the sign at MP 18 

became conspicuous after the train had passed a grade crossing at MP 17.34. After the crossing, 

the MP 18 sign was visible for up to 10 seconds, although the numbers on the sign could not be 

read until the train was about 4 seconds away. NTSB investigators noted that when the train 

approached the sign, headlights from automobiles heading north on a street that ran parallel to the 

tracks could be seen from the operating compartment. However, the automobile headlights did not 

appear to ‘wash out’ the sign.

Amtrak’s road foreman of engines OJT told investigators that he was about as familiar with 

the territory as any other engineer. He stated, “there was nothing significant” in terms of physical 

characteristics to remind himself of the upcoming curve. He did not have a good marker for himself 

for knowing when to slow down.
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The road foreman who qualified the engineer stated that he used CP 188 as a marker of 

when to begin slowing down. He specifically instructed crews to start slowing the train before 

passing the signal for CP 188 (about 1 mile prior to the curve).

The engineer believed the more he operated on a new territory, the more likely he was to 

use external cues to help identify where he was on the tracks. On territories where he had extensive 

operating experience, he cited stationary objects as potential cues, including bridges, buildings, 

siding switches, and very often signals.

1.8.5 Familiarity with the Siemens Charger Locomotive

In the summer of 2017, the Amtrak 501 engineer participated in training on the Siemen’s 

Charger locomotive. His training class had a single instructor and about a dozen students. The 

training included general information during classroom instruction.

Students also went inside the locomotive and got exposure to the display screens and 

controls. Students toured the engine room and received instruction on its mechanical features. 

However, students were not able to operate the Charger locomotive at that time. According to the 

engineer, neither his classroom training nor his qualification rides included the activation of the 

overspeed alarm.

Amtrak’s road foreman of engines OJT indicated that the controls for the Charger 

locomotive were like other locomotives. He added that the overall cab environment would feel 

new to the operating crews. He suggested that the screen displays were different and switches, 

such as the alerter reset button, were not the same.

A BLET local chairman told investigators that some engineers felt they were given 

adequate amount of time training on the Charger locomotive, while others believed they could 

have benefited from additional time. The local chairman told the engineers that those who felt they 

needed additional training should have requested it, and he was confident that Amtrak would have 

provided the additional training. However, he was not aware of any engineer asking for additional 

training.

The engineer operated the Charger locomotive on some, but not all, of his qualificatio n 

rides. The engineer told investigators, “I wouldn’t have run the [Charger] locomotive if I didn’t 

feel comfortable with it.”

The engineer stated that he had about 60 seconds to familiarize himself before departing. 

The train 501 engineer told investigators that during his accident trip he felt comfortable operating 

the Charger locomotive and was getting a feel for the gauges and an understanding where to look. 

He believed that he was focusing on the gauges more often than on a locomotive that he was more 

familiar operating. He was aware of blind spots in the periphery of the cab but did not need to 

change his operating strategy because of them.

As noted earlier in the accident narrative, the locomotive overspeed alarm was activated 

approaching the accident curve. The alarm was triggered when the locomotive exceeded 82 mph 

and not for the upcoming speed restriction at the curve. The engineer said he was familiar with 
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overspeed alarms on other locomotives but had not experienced one (either the visual or audio 

component) on the Charger locomotive until the accident trip. His first indications were the series 

of beeps and the illuminated lights emanating from the control panel at 7:33:20, about 27 seconds 

before the derailment. However, he did not know their meaning. He told investigators, “some of 

our locomotives will go into penalty without an alarm and other locomotives will give an alarm 

before going into a penalty, and I wasn’t sure what it was.”24 After not seeing any penalty lights, 

he ascertained that “I wasn’t in penalty, that it was just a warning, so I released the brake.” (Event 

recorder data does not indicate that he had released the brake before the train derailed).

1.8.6 Crew Responsibilities

An Amtrak road foreman told investigators that the qualifying conductor is, “basically part 

of the crew... They’re supposed to be calling out signals together, any restrictions” and can help 

with radio communications.25

After departing the Seattle station, the engineer and qualifying conductor called out some 

of the wayside signals. The qualifying conductor told investigators that the engineer’s 

responsibility was to call the signals by radio to the conductor back in the passenger railcars, and 

that those two agree with the current signal.

The engineer told investigators that he had no expectations that the qualifying conductor 

would help him with train operations, including locating wayside signs, during their trip since the 

qualifying conductor had not previously traveled over the Lakewood Subdivision. The qualifying 

conductor also told investigators about his expectations of his role on this trip while he was 

qualifying on the territory. He stated:

As a qualifying employee, learning the physical characteristics of the territory... 

you have no involvement with the operation of the train... just strictly observation 

first and foremost because you’re learning the route. That’s the whole purpose of 

you being there.

1.9 Damages Estimates

Sound Transit estimated the initial total track structural damages at $125,000. The damage 

to the bridge over I-5 was estimated at $225,000. In addition, repairs to a retaining wall and 

drainage cost $85,000.

The information in table 2 is the damage estimate for train 501. It was provided by Amtrak.

 24 When a locomotive “goes into a penalty,” the air brakes are automatically applied with either a service or 

emergency application, and the power is reduced to idle. The only response available to the engineer is to wait for the 

train to stop and reset the system. The FRA indicated that they had tested some other locomotives and they all gave 

an overspeed audible alarm warning.

25 The duties of the crewmembers are covered in the Operating Rules, Special Instructions, and the General 

Order.
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Table 2. Train 501 damage estimate.

Equipment Ownership Disposition Damage Estimate

WDTX 1402 State of Washington Total loss $7,237,000.00

AMTK 7903 State of Washington Total loss $2,712,000.00

AMTK 7454 State of Washington Total loss $1,298,000.00

AMTK 7554 State of Washington Total loss $1,298,000.00

AMTK 7804 State of Washington Total loss $2,005,000.00

AMTK 7303 Amtrak Total loss $2,005,000.00

AMTK 7504 State of Washington Total loss $1,298,000.00

AMTK 7424 State of Washington Total loss $1,298,000.00

AMTK 7423 State of Washington Total loss $1,298,000.00

AMTK 7422 State of Washington Total loss $1,298,000.00

AMTK 7421 State of Washington Total loss $1,298,000.00

AMTK 7420 State of Washington Total loss $1,298,000.00

AMTK 7102 State of Washington Total loss $1,062,000.00

AMTK 181 Amtrak Undamaged $0.00

TOTAL $25,405,000.00

1.10 Equipment Information

All railcars in this report will be identified by their equipment number followed by a 

number that represents their position in the train, such as AMTK 7903 (2). Train 501 was 649-feet 

long and weighed 920,000 pounds. The P-42 locomotive on the rear of the train and the bistro 

railcar AMTK 7303(6) were owned by Amtrak. The Charger locomotive and the rest of the Mt. 

Adams trainset were owned by the Washington State Department of Transportation (WSDOT) and 

operated by Amtrak under contract agreements. (See table 3.)

Table 3. Train 501 equipment information.

Sequence Car type Road number Weight (lbs.) Length 

(feet)

1 Locomotive WDTX 1402 265,000 71.5

2 Power AMTK 7903 43,220 38.7

3 Passenger, business class AMTK 7454 30,650 43.1

4 Passenger, business class ADA AMTK 7554 30,650 43.1

5 Passenger, dining AMTK 7804 27,780 43.1

6 Passenger, bistro AMTK 7303 31,090 43.1

7 Passenger, coach class ADA AMTK 7504 31,090 43.1

8 Passenger, coach class AMTK 7424 31,090 43.1

9 Passenger, coach class AMTK 7423 31,090 43.1

10 Passenger, coach class AMTK 7422 31,090 43.1

11 Passenger, coach class AMTK 7421 31,090 43.1

12 Passenger, coach class AMTK 7420 31,090 43.1
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Sequence Car type Road number Weight (lbs.) Length 

(feet)

13 Baggage AMTK 7102 39,690 38.7

14 Locomotive AMTK 181 268,000 69.0

Totals 922,620 648.9

1.10.1 Lead Locomotive WDTX 1402 (1)

This Siemens Charger passenger locomotive (SC44) is a 4,400 horsepower diesel-electric 

alternating current (AC) locomotive manufactured by Siemens Mobility in Sacramento, California.

WDTX 1402 (1) was released from the Siemens Mobility factory on March 30, 2017. WDTX 1402

(1) underwent final acceptance by Amtrak, WSDOT, and Siemens for use as a lead locomotive in 

revenue service on November 17, 2017. WDTX 1402 (1) was first used in revenue service on 

December 10, 2017, and operated on five revenue trains until the incident.

1.10.2 Passenger Equipment

The Talgo Series VI trainsets were manufactured by Talgo for Amtrak and WSDOT 

between 1996 and 1998. This trainset was built in 1998. One 12-unit trainset and four 13-unit 

trainsets were produced, four of which were put into service on the Cascades line between 

Vancouver, British Columbia, and Eugene, Oregon, with major stops in Seattle, Washington, and 

Portland, Oregon, starting in 1998. A fifth trainset was originally slated for Amtrak service 

between Los Angeles, California, and Las Vegas, Nevada, but was eventually purchased by 

WSDOT and was the accident train’s equipment.

The semipermanently coupled configuration of the trainset requires a long facility to be 

able to effectively service the railcars without uncoupling them. A special facility owned by 

Amtrak was built in Seattle to maintain the Talgo trainsets, with maintenance work completed by 

Amtrak agreement labor under Talgo supervision.

1.10.3 Rear Locomotive AMTK 181 (14)

AMTK 181 (14) is a P42-8 Genesis locomotive manufactured by General Electric in 2001. 

Amtrak owns, operates, and maintains a fleet of 191 P42 diesel locomotives and 13 identical P40 

locomotives for use across the nationwide network in both regional and long-distance services.

1.10.4 Predeparture Inspections

On December 18, 2017, Amtrak qualified inspectors conducted an air brake test with no 

exceptions and a pretrip inspection on the entire train.26

Train 501’s consist originated at the Amtrak Holgate Street yard and daily inspections were 

completed on both locomotives with no exceptions. However, while Amtrak mechanical personnel 

performed a sequence test to properly set up the locomotives in the consist, a minor electrical fault 

 26 Having no exceptions, is equivalent to having no problems.
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occurred that was corrected by mechanical personnel. Train 501 departed safely after incurring a 

9-minute delay. (This was the cause of delay mentioned in section 1.2 of this report.)

1.10.5 Locomotive Postaccident Inspections

On February 23-24, 2018, WDTX 1402 (1) was examined. With the extensive damage, an 

auxiliary air compressor had to be connected to the locomotive. When tested, the brakes applied 

and released properly on the locomotive from both service and emergency applications.

On January 31, 2018, locomotive AMTX 181 (14) was static tested with an exemplar 

locomotive WDTX 1401 at the Amtrak Seattle maintenance facility. The control cable was 

connected between the two locomotives. The control cable circuitry was checked and locomotive 

AMTX 181 (14) functioned as designed with no failures.

1.11 Crashworthiness and Derailment Description

1.11.1 Talgo Railcar Design 

The Talgo passenger equipment has a unique design, different from conventional United 

States passenger equipment. (See figure 5.) Several references are made to specific nomenclatures. 

The illustrations below serve as a key to those railcar parts and structures.

Figure 5. Side view of the Talgo trainset.

The Talgo Series VI trainset is designed with one rolling assembly located between each 

railcar, except for the baggage car (in the rear) which has two. Except for the baggage car, the 

railcars, when joined together to form the trainset, include one rolling assembly attached to the end 

of a railcar, referenced as the supported end, and a support structure installed on the end of the 

joining railcar, referenced as the suspended end. The suspended end of the railcar is attached to 

the end wall of the supported end of the railcar. The accident train was configured to have the 

supported end of each railcar oriented south or leading in the direction of travel. Front and rear 

orientations are established as follows: the supported ends will be referred to as the front or the 

leading end of the railcar. The suspended end will be referred to as the rear or trailing end. (See 

figure 6.)
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Figure 6. Talgo passenger railcar.

The supported end of the railcar, shown in figure 7, consists of the rolling assembly (shown 

in grey), the tower assembly (green), and the air spring suspension (blue). In this report, we refer 

to the complete system as the rolling assembly.

Figure 7. Supported end of Talgo railcar.
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The rolling assembly is attached to the two adjacent railcars through an upper and lower 

steering link. The rolling assembly retention system includes primary retention cables, tower straps

(red), and lower retention straps. In figure 8, to the left, the steering links are shown in yellow. In 

figure 8 to the right, the primary retention cable is shown in green, the tower strap is shown in red,

and the lower retention straps are shown in orange.

Two weight bearer bars shown in red in figure 8 are attached to the supported end at the 

top near the air suspension and are joined at the bottom of the suspended end. The weight bearer 

system supports the vertical loads between each railcar.

Figure 8. Rolling assembly cutaway and its side view.

The suspended end of a railcar consists of the weight bearer bars (two) shown in red in 

figure 8. These bars are attached through bolted connections to the supported railcar. The upper 

and lower guidance arms are shown in yellow in figure 8. As discussed previously, the guidance 

arms serve as the primary attachment of the rolling assembly to the railcar bodies.

The rail car-to-car connection or articulated connection (shown in figure 9) consists of two 

fixtures, each one attached to the railcar’s structure, a shank that joins them together, some stops 

(buffers) which are mounted on lateral supports to transmit the lateral forces, and a rubber plate 

which provides it with a certain elasticity when it transmits compressive forces.
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Figure 9. Articulated connections. The image on the right side is mirrored.

The design of articulated connections and railcars supported from an overhead support 

(tower assemblies) allows the railcars to swing like a clock pendulum. The railcars will swing 

when encountering a curve with super elevation.27 This passive movement shifts the center of 

gravity further towards the inside of a curve allowing Talgo equipment higher speeds on curves 

compared to traditional passenger equipment. Because of this difference, there were three 

designations of speeds in Sound Transit’s timetable. One was for freight trains, a second was for 

traditional passenger trains, and a third was for the Talgo trainsets.

 27 A super elevated curve is maintained with the outside rail of the curve higher than the inside rail like a banked 

race track. This realigns the center of gravity of the vehicle to the inside of the curve to offset the centrifugal forces to

the outside of the curve and allows for greater speeds through the curve.
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1.11.2 Derailment Description

The resting location of train 501 following the derailment is shown in figure 10. The 

locomotives, passenger railcars, and detached rolling assemblies are labeled and will be discussed 

individually.

Figure 10. Overhead with railcar positions labeled. Railcar 7421 was on top of railcar 7424, 

which is faded because it was under the overpass. (Photo provided by WSP.)

The locomotive derailed on the high side of the curve to the right and traveled through the 

ballast, down the embankment through a wooded area, and came to rest at about highway mile 

marker 116.6 on the southbound lanes of I-5. It came to rest upright in the original direction of 

travel, however, the damage on the right side of the locomotive was consistent with it being on its 

side at some point during the derailment.

The lead locomotive detached from the power railcar, AMTK 7903 (2).

28 The power railcar

and passenger railcars, AMTK 7454 (3), 7554 (4), 7804 (5), 7303 (6), followed a similar trajectory 

as the lead locomotive and came to rest in the wooded area. AMTK 7903 (2) came to rest partially 

on the interstate and rotated clockwise about 90° from its original direction of travel and onto its 

left side. Passenger railcars AMTK 7454 (3), 7554 (4), 7804 (5) and 7303 (6) remained coupled 

and upright. Passenger railcar AMTK 7504 (7) rotated 180° from its original direction of travel 

and came to rest with its rear left side on top of the AMTK 7554 (4) and its front left side leaning 

against AMTK 7804 (5).

 28 The power car on this Talgo trainset provides power for lighting, convenience outlets, doors, and other systems 

that are not housed in the other individual cars. The power car does not provide traction power and is not intended to 

control the train. It resides at the front of the trainset, and is not intended to carry passengers.
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The power railcar, AMTK 7903 (2), followed a similar trajectory as WDTX 1402 (1) 

through the woods. It traveled about 341 feet from the point of derailment (POD). The mechanical 

coupler between the power railcar and the locomotive fractured. (The Talgo consist is equipped 

with a standard AAR “H” tightlock coupler at each end, to allow coupling to a locomotive at each 

end.) AMTK 7903 (2) came to rest on its left side, rotated about 90° from its original direction of 

travel. AMTK 7903’s (2) rear end structure abutted the front of AMTK 7454 (3) and witness 

indications were consistent with a collision with the orange trailer of a tractor and semitrailer 

(semitruck) that was traveling southbound on I-5.

AMTK 7454 (3) followed a similar trajectory as AMTK 7903 (2). The clockwise rotation 

of AMTK 7903 (2) pushed AMTK 7454 (3) in a counterclockwise rotation about 37° from its 

original direction of travel. It came to rest on the interstate about 314 feet from the POD. The 

articulated connection of AMTK 7454 (3) and AMTK 7554 (4) remained intact. Impact indicatio ns 

were observed between the end wall structure of AMTK 7554 (4) and AMTK 7454 (3). Further 

details of the articulated coupler connections can be found in section 2.6 of this report. The rolling 

assembly from AMTK 7454 (3) separated from its attachments, however, the assembly remained 

near the supported end of this railcar. (See figure 11.)

Figure 11. Detached rolling assembly from AMTK 7454 (3). (Photo provided by WSP.)
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AMTK 7424 (8) traversed along the east (left) side of the track down the embankment and 

onto the highway coming to rest under the bridge overpass on its roof with its lead-end facing 

north. AMTK 7423 (9) and 7422 (10) came to rest on the bridge oriented laterally across the track. 

AMTK 7423 (9) was rotated about 50° counterclockwise to the track. AMTK 7422 (10) rotated 

about 120° clockwise to the track with the leading end of the railcar’s left corner extending over 

the embankment.

Six articulated connections failed (the principal connections responsible for connecting the 

Talgo railcars together). These connections will be discussed in section 2.6 of this report.

Five rolling assemblies from the Talgo passenger railcars fully detached during the 

derailment and one partially detached. One of the fully detached rolling assemblies collided with 

passenger railcar, AMTK 7504 (7), in which three passengers were killed. (See figure 12.)

Figure 12. Detached rolling assembly tower partially inside AMTK 7504(7).

Rolling assemblies are located at the leading end (oriented relative to the direction of travel) 

of the 12 semipermanently coupled railcars. The rolling assembly from AMTK 7424 (8) was 

located underneath the bridge next to the left guardrail on the south lanes of I-5. The rolling 

assembly from AMTK 7421 (11) was located behind a Ford pickup truck on the south lanes of I-5. 

(See figure 13.)
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Figure 13. AMTK 7421 (11) resting on AMTK 7424 (8). (Photo provided by WSP.)

As the lead locomotive and the first six passenger railcars of the train derailed to the right 

of the main track and down the embankment, the articulated connection between AMTK 7504 (7)

and AMTK 7424 (8) fractured. AMTK 7504’s (7) articulated coupler connection with AMTK 

7303 (6), was also fractured.

The railcars trailing behind AMTK 7422 (10) then traveled to the left of the main track. In 

the aerial photograph visible marks in the ballast and soil show the path of travel of the separated 

train. (See figure 14.)
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Figure 14. Derailing path of travel of Amtrak 501. (Photo provided by WSP.)

The lead locomotive, WDTX 1402 (1), received impacts to the front top section of the cab. 

The cab roof deformed into the operator’s compartment about 13 inches. The roof panels sheared 

off, exposing the machine room compartments. The right side of the locomotive exhibited 

horizontal scrape marks along its full length and mud, dirt, wood, and rocks were lodged into the 

side panels, consistent with the locomotive proceeding through the woods on its side. The 

locomotive came to rest about 457 feet from the POD, on the interstate, upright and forward facing, 

indicating it righted itself as it moved through the wooded area, impacting the adjacent trees and 

passing through the highway guardrail, which was located beneath the locomotive. (See figure 15.)
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Figure 15. WDTX 1402 (1) postderailment position.

During interviews with highway vehicle operators, a driver of a white Toyota RAV4 said 

she was traveling southbound in the right lane when her vehicle was struck from behind by the 

locomotive. The vehicle came to rest on the left side of the roadway, facing north in the southbound 

lane. (See figure 16.)
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Figure 16. Highway vehicle struck by lead locomotive. (Photo provided by driver.)
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1.11.3 Locomotive Crashworthiness Requirements

Locomotive crashworthiness requirements in the United States are governed by FRA 

regulations and AAR standards. The FRA regulations are outlined in Title 49 Code of Federal 

Regulations (CFR) Part 229, Subpart D, “Railroad Locomotive Safety Standards” and, 49 CFR

Part 238, Subpart C, “Passenger Equipment Safety Standards.” The following AAR standards are 

incorporated by reference: AAR S-580, AAR Manual of Standards and Recommended Practices, 

Section M, Locomotives and Locomotive Interchange Equipment, Standard S-580, Locomotive 

Crashworthiness Requirements and AAR S-5506, AAR Manual of Standards and Recommended 

Practices, Section M, Locomotives and Locomotive Interchange Equipment, Standard S-5506, 

Performance Requirements for Diesel Electric Locomotive Fuel Tanks. The Siemens locomotive 

was designed to meet all United States requirements. (See figure 17.)

Figure 17. Siemens Charger locomotive crashworthiness features.

1.11.4 Postaccident Observations and Inspections

As a result of the derailment, there were some localized deformations at the front of the 

operating cab above the corner and collision posts. The operating cab windshield was destroyed;

however, the laminated safety glass feature prevented the shattered glass from separating into 

pieces. The right side of the locomotive exhibited nonstructural compromised sidewall damage 

consistent with the locomotive being on its side. Abrasions were visible along the entire length, 

from the side sill (lower portion along the floor line) to the roof. The rear-end wall structure was 

severely loaded during the derailment and was separated from the right-side wall connections. The 

left-side connections remained intact. Damage along the left side was minimal. The roof panels 

(three total) were severed from their connections. (See figure 18.)
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Figure 18. Damage to WDTX 1402 (1).

The damaged equipment was stored at the nearby military base, Joint Base Lewis-McChord

(JBLM). Under the direction of the NTSB, Siemen’s engineers examined the locomotive in 

January 2018. They reported there were no visual separations of the corner and collision posts, or 

visual separations or ruptures of the welded seams. Both side entry doors of the engineer’s cab and 

the machine room access door were operable. The underframe was locally deformed, but the 

structural condition was intact. The crash energy management (CEM) features in the front and rear 

coupler was not activated. Both trucks and their retention mechanisms remained intact and 

attached to the locomotive. The fuel tank and the fuel tank inlet were not compromised because of 

this derailment.

1.11.5 United States Passenger Railcar Crashworthiness Standards

At the time the Talgo railcars were delivered to WSDOT, passenger railcar crashworthiness 

requirements were limited to a static end strength of 800,000 pounds. The requirements were 

prescribed in AAR Standard S–034–69, Specification for the Construction of New Passenger 

Equipment Cars, published in 1969. Section 6, paragraph (a), of the specification required that the 

railcar structure shall resist a minimum static end load of 800,000 pounds at the rear draft stops 

ahead of the bolster on the center line of draft, without developing any permanent deformation in 

any member of the railcar structure. The static end-strength requirement was based on 

longstanding practice and originated in specifications for United States Railway Post Office (RPO) 

railcars in the 1940s (Tyrell, 2001) (Blaine, 1979). Numbers of earlier RPO railcars, which were 

built to lower static end strength requirements, were crushed in train collisions. During a collisio n, 
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substantial compressive loads would be applied to such railcars. For railcars not built to the 

800,000 pounds static end strength requirement, the results could be catastrophic, with structural 

collapse of the railcars and many postal workers killed. The introduction of railcars that met the 

800,000 pounds static end strength requirement effectively eliminated this type of complete 

structural collapse.

On May 12, 1999, the FRA published a final rule, 49 CFR Part 238, “Passenger Equipment 

Safety Standards.” In the section “Structural Standards for Existing Equipment,” the final rule 

requires that all passenger equipment (other than locomotives that comply with an alternative 

standard as specified; private railcars; unoccupied vehicles operating at the rear of a passenger 

train; or equipment used in noncommingled service, as discussed below) in use on or after 

November 8, 1999, have a minimum static end strength of 800,000 pounds as specified in 49 CFR

238.203.

In addition to the static end strength requirement, requirements in the 1999 final rule for 

passenger railcar strength included: (summarized)

• Anticlimbing mechanism at the forward and rear ends capable of resisting an 

upward or downward vertical force of 100,000 pounds without failure

• Link between coupling mechanism and car-body such that equipment shall have 

a coupler carrier at each end designed to resist a downward thrust from the 

coupler shank of 100,000 pounds for any normal horizontal position of the 

coupler without permanent deformation

• Two full height collision posts having an ultimate shear strength not less than 

300,000 pounds at a point even with the top of the underframe member to which 

it is attached

• Two full height corner posts capable of resisting a horizontal load of 

150,000 pounds at the point of attachment to the underframe without failure

• Truck-to-car-body attachments shall have a truck-to-car-body attachment with 

an ultimate strength sufficient to resist, without failure, the following 

individually applied loads: 2 g-force [gravitational force] vertically on the mass 

of the truck; and 250,000 pounds in any horizontal direction on the truck, along 

with the resulting vertical reaction to this load

1.11.6 Talgo Crashworthiness Design

The Talgo passenger trainset was originally designed to meet the International Union of 

Railways (UIC) design codes (also known as leaflets). The codes include several design standards 

much like the AAR design standards in the United States. Specific to the construction of the railcar

body, the Talgo passenger railcars were designed to meet the UIC-566, Loadings of Coach Bodies 

and their components, revision January 1990.
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According to UIC-566, the body of the passenger railcar comprises the underframe, the 

side walls, the end walls, and the roof which form a tubular beam. The principal design 

characteristics of the railcar which are, according to the leaflet, obligatory provisions, are as 

follows:

The end walls, strengthened by anticollision pillars, shall be so joined to the 

headstocks, cant-rail and roof that the maximum amount of energy is absorbed first 

by deformation of the end wall section before the passenger compartments are 

deformed.

The coach body, in running order and mounted on the bogies [truck or rolling 

assembly], shall be designed that under all conditions, its natural frequencies differ 

from the hunting and pitching frequencies of the bogie, so that no resonance occurs 

throughout its speed range.29

The railcar body shall be designed to withstand a 2000kN [449,617 pounds, less 

than United States standards] static compressive loads at the buffer or coupler level

without permanent deformation. UIC-566 does not prescribe a structural strength 

requirement for anticollision pillars at the railcar ends.

Additional requirements in UIC-566 include the strength of the component parts mounted 

on coaches and the loads developed resulting from buffing impact (collisions). Mounted 

component parts shall be designed to resist the following gravitational forces (g):

30

• Longitudinally: 5g

• Transversely: 1g

• Vertically: (c)g (including gravity), where c = 3 at the end of the coach, falling linearly 

to 1.5 at the coach center

For the end railcar, the power railcar and the baggage railcar, Talgo designed these to be 

more restrictive than the requirements in UIC-566. (See table 4.)

Table 4. UIC-566 compared with Talgo end car design load cases.

Load case Talgo requirement UIC-566

Longitudinal 6g 5g

Lateral 3g 1g

Vertical 3g c

Main attachments loading cases.

 29 (a) Bogie refers to the wheel-axle-frame assembly under each end of a car or locomotive. (b) Natural frequency 

in this context refers to a frequency at which an object(s) will vibrate at a specific rate called the object's natural, or 

resonant, frequency. Such an object(s) if not properly designed will vibrate strongly when it is subjected to vibrations 

at a frequency equal to or very close to its natural frequency potentially impacting ride quality and in severe cases can 

cause derailment.

30 Gravitational force refers to the force of gravity or the force of acceleration. It is measured in g’s, where 1 g is 

equal to the force of gravity at the Earth’s surface.
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According to Talgo, no specific requirements are prescribed in UIC-566 for retention of 

rolling assemblies.

1.11.6.1 Grandfathering Talgo Passenger Railcars

Because of the enactment of FRA’s 1999 final rule, Amtrak, by letter dated October 18, 

1999, petitioned the FRA pursuant to 49 CFR 238.203(d) to grandfather or permit the use of Talgo 

articulated trainsets on three corridors: the Pacific Northwest corridor between Eugene, Oregon,

and Blane, Washington, via Portland and Seattle, the Southern California corridor between San 

Luis Obispo and San Diego via Los Angeles; and the corridor between Los Angeles and Las Vegas,

Nevada. FRA approval was required because the trainsets did not meet the required compressive 

strength of 800,000 pounds applied at the coupler faces without permanent deformation of the 

body structure.

Title 49 CFR 238.203(d), “Grandfathering of non-compliant equipment for use on a 

specified rail line or line,” provides a provision for a railroad to petition the FRA to permit the use 

of rail equipment not meeting the then-newly published requirement(s). The petitions submitted 

were required to include (summarized): detailed drawings and material specifications, engineering 

analysis sufficient to describe the performance of the static end strength and its performance in a 

collision, risk mitigation efforts employed in connection with the use of the equipment and a 

quantitative risk assessment demonstrating the use of the equipment in the service environment, is 

in the public interest and is consistent with railroad safety.

The FRA received a substantial number of filings for this petition, and several were quite 

extensive.31 A public hearing was held on July 21, 2000, at which testimony was received from 

Amtrak, WSDOT, Talgo, the National Association of Railroad Passengers, the American Public 

Transportation Association, and Bombardier. The FRA considered the public comments in 

reaching their preliminary decision in September 2000 and subsequently authorized the use of 

Talgo Series VI subject to certain conditions.

The following is a summary of select conditions required:

• The railcars must be modified to increase the strength of the weight bearing 

bars (two per railcar) and their related supports to the railcar structure, to 

withstand, at a minimum, a 100,000-pound vertical load, applied either up or 

down

• The railcars must be modified by applying safety cables between the railcars

and bogies to resist a minimum total longitudinal force of 77,162 pounds to 

resist separation of the railcar-bodies and rolling assemblies

• The railcars must be modified by applying safety cables around the top of each 

suspension column, affixed to the upper structure of the railcars to resist the 

application of a nominal 250,000-pound force, applied at the center of gravity 

of the rolling assembly

 31 See the FRA public docket at https://www.regulations.gov/docket?D=FRA-1999-6404. 
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• Amtrak must operate the railcars in dedicated trainsets as proposed in their 

submission. When operating in revenue or deadhead service, the baggage and 

power railcars shall be placed at the ends of the remaining railcars in the trainset 

and must not be occupied by passengers or crew

• The trainsets may be operated in either locomotive-hauled or push-pull service. 

In locomotive-hauled service, the trainset may be followed by a 

locomotive-type cab control railcar (such as depowered F40) at Amtrak’s 

election. In push-pull service, revenue and deadhead trains must be operated 

with a locomotive or locomotive-type cab control railcar on both ends. In either 

locomotive-hauled or push-pull service, additional equipment in the train 

consist (such as passenger railcars, freight railcars, materials handling railcars, 

and bimodal equipment) is prohibited

• Maximum operating speed is 79 mph

• Amtrak must prepare an engineering analysis reviewing the design and 

securement of the steel structure affixed to the power railcar and the baggage 

railcar that contains the draft gear and collision posts

In making its final decision, the FRA established that they [FRA] must determine if in the 

context of a particular rail operation, the absence of otherwise compressive end strength causes the 

equipment to fall short of the performance expected of equipment having the otherwise required 

strength, so that its use was consistent with railroad safety. According to the FRA, the central 

purpose of buff strength is to ensure adequate compatibility among units of rolling stock used on 

the general railroad system with respect to collision risk. In making its final decision, the FRA 

reviewed the petition and all available information related to the construction of the Talgo trainsets, 

including (summarized):

• Results of finite element analysis provided to Amtrak by Talgo

• A one-dimensional lumped mass analysis conducted by LTK Engineering for 

Amtrak

• Photographs of accidents in Europe involving equipment of similar 

construction

• Public comments

In addition to the relevant information above, the FRA also considered (summarized):

• A risk assessment completed for Amtrak by Arthur D. Little Inc. (ADL). The 

risk assessment evaluated the impact of using Talgo trainsets in the Pacific 

northwest

• A crashworthiness evaluation of the Talgo Series VI completed by the John A. 

Volpe National Transportation Systems Center (Volpe)
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• An FRA engineering staff inspection of Talgo equipment and review of 

operational issues that would have arisen since the introduction of the 

equipment

• Additional risk assessments by ADL

Overall, the FRA concluded that the engineering and other analysis provided assurances 

that the Talgo equipment could be expected to operate safely on the basis of moderate energy 

events (50 mph or less) which would present a higher probability of occurrence than more severe 

events.

In its docket, the FRA expressed concern regarding the expected performance of the Talgo 

equipment in higher energy events. The FRA stated that at closing speeds (referring to collisio ns), 

the Talgo train was expected to experience a greater lateral displacement than conventio nal 

equipment, and articulated connections were expected to fail. Thus, in collisions greater than 25 

mph, the following dangers could arise (summarized):

• With failure of the articulated connectors that suspend the railcar bodies, in the 

absence of compressive forces, the light railcar bodies would be free to fall to 

the track structure or surrounding terrain with unknown results. (Conventio nal 

railcars are supported by trucks designed to remain attached except under very 

unfavorable circumstances)

• Comparatively greater lateral displacement of the passenger units would create 

a greater hazard of secondary collisions (such as by fouling an adjacent main 

line or impacting with a bridge structure or abutment)

In summary, the FRA determined that there was sufficient information submitted to 

establish that the five Talgo Series VI trainsets could be operated consistent with railroad safety in 

the Pacific Northwest Corridor at speeds up to 79 mph subject to specific conditions tied to the

review and approval of the train control system.

Amtrak and Volpe had provided and developed information to characterize the 

crashworthiness of the trainsets under the conditions specified. However, given the uncertainty 

related to the crash analysis, risk assessment, and other issues discussed above, the FRA 

determined that the conditions attached to their approval would be necessary to secure a reasonable 

level of confidence such that safety would not be compromised.

Final approval was granted by the FRA on March 27, 2009, for the operation of 67 Talgo 

Series VI railcars (five trainsets) having met the conditions discussed above along with

(summarized):

• Restricted to operations between Eugene, Oregon, and the United 

States/Canadian border near Blaine, Washington, and the route between Los 

Angeles, California, and Las Vegas, Nevada

• Operations on the Pacific Northwest Corridor are authorized, consistent with 

other railroad safety regulations (including, for example, 49 CFR213.345) only 
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upon acceptance by the associate administrator for railroad safety/chief safety 

officer of plans for, and installation of, a train control system meeting the 

requirements of 49 CFR Part 236

1.11.7 Test and Research

A selection of intact safety straps from the accident trainset and from an exemplar trainset 

were retained by the NTSB Materials Laboratory for further examination and mechanical testing. 

Tests to determine the tensile breaking strength for each of the submitted straps were completed. 

Results of the testing, documented in Materials Laboratory Factual Report 18-042, showed the 

straps fractured at loads that were about 10 to 50 percent of the breaking strength of 38,500 pounds. 

(See section 2.6 in this report for further discussion.) Full results of the testing are documented in 

Materials Laboratory Factual Report 18-042.

1.11.8 Vancouver Talgo Derailment

While investigating the DuPont accident, investigators became aware of a Talgo Series VI 

trainset derailment that occurred with Amtrak Train 516 in Vancouver, British Columbia, on 

December 17, 2018.32 The derailment occurred at the Canadian National Railway Company (CN) 

Yard at MP 130.8, Yale Subdivision, about 1 mile south of the Vancouver Pacific Central Station. 

The train derailed while moving over a switch, and two railcars from the trainset struck a nearby 

freight railcar parked on an adjacent track. There were no injuries reported by crew or passengers,

and according to Amtrak, the train was moving at 3 mph. The NTSB traveled to Seattle, 

Washington, to examine the trainset after it was moved from Vancouver. Two Talgo Series VI 

passenger railcars exhibited sidewall damage consistent with a raking collision. One of the railcars

exhibited two tears in the sidewall near the side passenger door. The door was also damaged during 

the collision and was removed during the recovery operation. The longest tear was measured to be 

about 4 feet in length occurring at the midpoint of the door, extending toward the passenger 

window. The other tear was measured at 18 inches in length. The side of the railcar was abraded 

from being in contact with the freight railcar. The height of the abrasion was measured at 38 inches. 

The passenger door was found inside of the railcar, placed there after the derailment. The door’s 

window was broken, and the exterior aluminum covering was torn and damaged. Based on all 

observations, there were no indications passenger-occupied space was compromised. The other 

passenger railcar was abraded along its side wall without significant compromise of the structure. 

There were two areas where the sidewall was torn and fractured. One passenger window was 

broken, likely from contact with the freight railcar when it derailed.

 32 The trainset involved was known as the Mt. Olympus trainset, so designated with branding on the side of the 

train.
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1.12 Survival Factors

This section of the report focuses on the issues related to the survivability of the passengers 

and the train crew that were traveling in the locomotive and passenger railcars, and the ability of 

the passengers and crew to safely evacuate the railcars. In this section, additional informatio n 

regarding the passenger railcar interior design, safety features, and exits are examined.

1.12.1 Locomotive Survival Factors

Damage to the interior of the operating cab was constrained primarily to the leading end, 

most notably at and above the front glazing (windshield). The vertical space of the cab interior was 

reduced to about 19 inches between the operator’s desk and the ceiling, and to 66 inches from the 

floor to the ceiling. The height above the seats was reduced to 66.5 inches. All doors, both side 

doors, and the machinery room access door, were fully functional after the accident. The cab 

ceiling emergency exit hatch was dislodged from the vehicle. The hatch is comprised of two parts;

the upper, or outer, part came to rest in the wooded area between the track and the interstate, and 

the inner portion was inside the cab. Investigators estimated the locomotive lost about 5 percent

of its occupied volume in the cab. Figure 19 is a cutaway illustration of the locomotive cab showing 

the cab design and underlying structure and an interior photograph of the accident cab taken from 

the left side of the cab towards the engineer’s seat on the right.

Figure 19. Pictures of the cab design and cab damage. (Photograph courtesy of Siemens.)
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1.12.2 Passenger Car Survival Factors

The exterior passenger door is 32-inches wide and when opened, automatic retractable 

steps extend to provide passengers with a means of stepping down from the train. These steps are 

located 16 inches above the top of the rail. Each service railcar is equipped with a hinged exterior 

access door for service personnel. This service door has an opening of 31 inches.

Each passenger railcar and the bistro and dining railcar are equipped with four emergency 

windows which can be accessed from the exterior by first responders or removed from the inside 

by passengers. These windows are comprised of double-paned laminated safety glass and marked 

for emergency egress. The remaining side windows are double-paned laminated glass that cannot 

be used for emergency egress. Window openings are about 53-inches wide and 29-inches tall.

The railcars are equipped with an internal glass door fitted with tempered safety glass that 

is located at either end of the railcar. The door is electrically powered. When the electrical power 

is removed, 20 pounds of force is required to manually open the door. In addition, at each end of 

the railcar, a small hammer is provided for passengers to use to break the door glass in the event 

the door fails to open.

The coaches are equipped with nine rows of double seats on each side of the aisleway. The 

first three rows and last row of seats do not rotate. Tables are provided for the seats located at the 

one end of the railcar. The business class has eight rows of double seats on one side of the aisle 

and a single seat in the last row. In business class, the first and last row of seats do not rotate. On 

the opposite side of the aisleway, there are nine rows of single seats. (See figures 20 and 21.)
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Figure 20. Talgo coach class seating layout.

Figure 21. Talgo business class seating layout.

Both wheelchair-accessible railcars have a single seat with the adjacent space available for 

a wheelchair-bound passenger, five rows of double seats and a single seat in the last row on one 

side of the aisleway. The other side of the aisleway has a space designated for a wheelchair bound 

passenger, and five rows of single seats. Wheelchair accessible railcars have two wheelchair lifts 

mounted to the frame of the railcar adjacent to the two exterior loading doors. (See figures 22 and 

23.)
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Figure 22. Coach class Americans with Disabilities Act (ADA) layout.

Figure 23. Business class Americans with Disabilities Act (ADA) layout.

There are two nonrevenue railcars, a dining railcar and a bistro railcar. The dining railcar

has a capacity for 30 diners. There are ten tables present in this railcar. Five of the tables will 

accommodate four diners and the remaining five accommodate two diners each. The bistro railcar

has a long counter-type surface that permits seven passengers to sit on stools in a “bar-like” 

atmosphere. There are also two small tables located to the rear and opposite side of the railcar. The 

bistro railcar also incorporates a kitchen area with a large sink, multiple ovens, and two work 

station tables.
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1.12.3 Postaccident Observations of Passenger Railcar Interiors

Investigators examined and assessed passenger interior damage resulting from the 

derailment with an emphasis placed on the loss of survivable occupant space and interior features 

that may have contributed to survivability within the railcar. The results of the observations are 

shown in table 5.

Table 5. Postaccident observations of passenger railcar interiors.

Car Interior Observations 

AMTK 7454 (3) Minor damage. Interior intact. No loss of survivable occupant space.

AMTK 7554 (4) Right side wheelchair lift was partially detached from railcar structure. Minor damage to 

left side wheelchair lift. Seat 4C on left side of railcar at point of deformation rotated 

towards aisleway. Ceiling panels displaced and deformation above Seat 4C. Glass 

divider for overhead luggage bin broken and found on floor. Minor damage to seat 

components (trays and cushions). No loss of occupant space.

AMTK 7804 (5) Right side interior ceiling collapsed. Right side tables and seats broken. Glass partitions 

between seating positions are broken on both sides of railcar. Seats shifted and 

deformed. Survivable occupant space present.

AMTK 7303 (6) Significant amounts of dirt and debris found inside of railcar. Partial collapse of overhead 

ceiling. Front emergency window frame and railcar bowed inward on right side. Wall 

mounted cabinet and counter displaced. Extensive damage to seating area. Survivable 

occupant space available.

AMTK 7504 (7) Extensive damage caused by separation of both wheelchair lifts from railcar body. 

Length of railcar shortened 4 feet, floor deformation at highest point 29.5 inches, roof 

collapse shortened height to 20 inches and compromised seats #17/18. Seat rotation, 

floor rise, and ceiling collapsed eliminated survival space except at seats #21, 22 and 

25. 60 percent of seats lost to crushing.

AMTK 7424 (8) Roof and luggage rack collapse reducing overhead space. Survival occupant space 

maintained at seats # 21 through 33.

AMTK 7423 (9) Last three rows of double seats rotated due to deformation to lower right sidewall. Right 

rear emergency window smashed due to impact with seat occupant. Rear glass partition 

behind last row of seats right side broken. Survivable occupant space available.

AMTK 7422 (10) Right side on fourth row, double seat (#21/22) rotated.

No loss of survivable occupant space.

AMTK 7421 (11) Table located on right side between first and second row of double seats broken due to 

penetration of railcar structure. Seat # 21/22 located four rows back on the right side 

found rotated. No effect on available occupant space.

AMTK 7420 (12) Minor damage. No loss of survivable occupant space.

1.13 Injuries

1.13.1 Locomotive

The locomotive engineer sustained blunt impact trauma to the head, facial fractures from 

impact with the interior structures that collapsed due to the impact with the trees and a fractured 

right elbow from impact with the console. The qualifying conductor, who was riding in the 

locomotive cab, sustained injuries to his lower extremities, back and spinal injuries and blunt 

impact trauma to his torso.
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1.13.2 Passenger Railcars

An assessment was conducted to the interior compartments based on the injuries sustained 

by the passengers and the damage to the railcars. Investigators were able to obtain the majority of 

the medical records for the injured passengers. Through interviews, the passengers provided their 

railcar and seat locations and an overview of the events that occurred in the passenger railcars. Ten 

passengers were either fully or partially ejected from the train during the derailment. Table 6 

summarizes this information.

Table 6. Breakdown of car occupant injuries.

Railcar Number Car 

Occupants

Fatal Serious 

Injury

Minor 

Injury

No 

Injury *Unknown 

Injury

Ejection Partial 

Ejection

AMTK 7454 (3) 3 0 1a 0 2 0 0 0

AMTK 7554 (4) 6 0 4 0 1 1 0 0

AMTK 7804 (5) 3 0 0 1 1a 1 0 0

AMTK 7303 (6) 2 0 1a 0 1 0 0 0

AMTK 7504 (7) 11 3 6 1 0 1 2 2

AMTK 7424 (8) 10 0 7 1 2 0 5 0

AMTK 7423 (9) 7 0 2 2 1 2 0 0

AMTK 7422 (10) 10 0 1 1 8 0 0 0

AMTK 7421 (11) 21 0 6 2 12 1 0 1

AMTK 7420 (12) 1 0 0 1a 0 0 0 0

Location 

unknown

7 0 2 1 3 1 0 0

Totals 81 3 30 10 31 7 7 3

* Investigators w ere unable to obtain the medical records for these individuals.

a Includes crew member.

1.13.3 Highway Vehicles

Southbound I-5 in DuPont, Washington, is a heavily traveled major arterial roadway that 

traverses the state of Washington north and south. It is the main thoroughfare between two of the 

state’s largest cities, Seattle and Tacoma.

The derailing Amtrak train struck several highway vehicles after it departed the right of 

way and entered the roadway. Additionally, parts of the train detached during the derailment and 

were involved in collisions with several vehicles on the Interstate. In all, eight vehicles were 

damaged resulting either from the collision with the derailing train or from detached train 

components or debris. In addition to the eight vehicle operators, there were two passengers 

traveling in the involved vehicles. A total of eight vehicle occupants were injured.

1.13.4 Highway Vehicle Accident Sequence

At 7:33 a.m., a Freightliner tractor in combination with an intermodal trailer was traveling 

at 61 mph southbound on I-5 as recorded by the truck’s Electronic Logging Device (ELD). In his 

interview with investigators, the truck driver said he was in the “center” lane. The truck driver 
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advised that about 3-4 miles before the accident, the train while traveling on the track, passed him 

on his right. The truck driver reports that he observed the entire train pass his truck which was 

traveling about 61 mph southbound on the interstate. As the truck driver approached the overpass, 

he said he observed AMTK 7424 (8) enter the roadway north of the overpass and strike his trailer. 

The railcar was already sliding on its roof when it entered the roadway. The impact from the railcar

damaged the steel intermodal trailer and pushed the truck out of its original lane of travel. As the 

railcar was dragged along the side of the trailer, it slowed the Freightliner to 23 mph.

The ELD recorded the time of the deceleration at 7:34 a.m. As the truck continued 

southward, passing under the overpass, it was struck by the power railcar, AMTK 7903 (2) that 

had entered the roadway just south of the overpass. The Freightliner came to final rest near the 

right side of the roadway. The truck sustained heavy damage to the cab, windshield, the engine 

and the engine cowling. Because of the damage sustained by the truck cab, the truck driver’s door 

became wedged and the truck driver was forced to climb out of the passenger window. The driver 

sustained minor injuries in the collision and required medical attention.

A Ford F-150 pick-up truck was damaged when AMTK 7454 (3) entered the roadway south 

of the overpass in front of it. The driver reported that he was unable to stop and struck the railcar. 

AMTK 7424 (8) collided with the rear of the truck as it slid to a stop on the interstate. The driver 

sustained severe injuries as did the front-seat passenger, who was trapped in the vehicle and had 

to be extricated by the first responders. (See figure 24.)

Figure 24. Final resting position of F150 and Freightliner. (Photo provided by WSP.)

A white Toyota RAV4 was traveling south in the right lane when the driver reported seeing 

debris flying along the right side of the interstate. The driver advised that it was at that point that 

her vehicle was struck from behind. The driver lost control of the Toyota which spun out of control 

crossing all the southbound travel lanes of the interstate. The vehicle came to final rest on the left 
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side of the roadway, facing north in the southbound lane. The subsequent investigation revealed 

that the Toyota RAV4 was struck from behind by the lead locomotive as it entered the roadway 

and slid to a stop on the interstate. The driver was treated for minor injuries at a local area hospital.

A green Kia Soul (Kia) and a black Jeep Grand Cherokee (Jeep) were struck by the rolling 

assembly weighing about 4,500 pounds that had detached from AMTK 7424 (8). (See figure 25.) 

The rolling assembly struck the front hood of the Kia and the rear of the Jeep; causing both drivers 

to lose control of their vehicles. The driver of the Jeep reported to investigators that AMTK 7424 

(8) also struck his vehicle. Both vehicles sustained extensive crush damage resulting from the 

impact with the rolling assembly. The driver of the Kia was pinned inside of her vehicle when the 

engine block was shoved rearward, collapsing the dashboard and steering column onto her. (See 

figure 26.) The driver had to be extricated by first responders but sustained only minor injuries in 

the accident. After being struck by the rolling assembly, the Jeep rotated 180° striking the metal 

guardrail before coming to final rest. (See figure 27.) The Jeep occupant also sustained minor 

injuries in the accident.

Figure 25. Detached rolling assembly and Grand Cherokee. (Photo provided by WSP.)
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Figure 26. Green Kia and rolling assembly on I-5. (Photo provided by WSP.)

Figure 27. Damaged Jeep Grand Cherokee. (Photo provided by WSP.)
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As a result of the accidents with the highway vehicles, eight people were injured in the 

highway vehicles. Table 7 describes the injuries in detail.

Table 7. Highway vehicle injury breakdown.

Vehicle Damage Occupants Injured Fatal Serious Minor

Ford F-150 Extensive 2 2 0 2 0

Freightliner 

tractor and trailer

Extensive 1 1 0 0 1

Kia Soul Extensive 1 1 0 0 1

Jeep Grand 

Cherokee

Extensive 2 2 0 0 2

Kenworth tractor 

and trailer

Moderate 1 0 0 0 0

Nissan Altima Moderate 1 0 0 0 1

Toyota RAV4 Extensive 1 0 0 0 0

Hyundai Santa Fe’ Extensive 1 0 0 0 0

1.13.5 Passenger Ejections

During the derailment, AMTK 7424 (8) detached from its leading and trailing railcar and 

struck the overpass concrete bridge abutment. The railcar then nosed downward, upended and 

overturned end over end while rotating 180°, finally resting on its roof while sliding to a stop on 

I-5 under the overpass. During the accident sequence, the structural supports that held the windows 

in place buckled and several of the windows broke out or fell out. Five passengers inside of the 

railcar were ejected out of the railcar and were, according to emergency responders, motorists and 

other passengers, found lying on the interstate.

As a result of the derailment, AMTK 7421(11) came to rest hanging from the overpass and 

resting on top of AMTK 7424 (8). (See figure 28.)
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Figure 28. AMTK 7421 (11) resting on AMTK 7424 (8). (Photo provided by WSP.)
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The separation of AMTK 7421 (11) from its lead railcar left an opening at the lowest point 

of the railcar, where it had been previously coupled. A female passenger sitting near the front of 

that railcar was thrown from her seat and partially ejected through the opening at the end of the 

railcar. (See figure 29.)

Figure 29. Open end of AMTK 7421 (11). (Photo provided by WSP.)

Two of the deceased passengers were ejected out of AMTK 7504 (7) when the side wall of 

the railcar was breached by the rolling assembly belonging to AMTK 7422 (10). The rolling 

assembly tore a hole into the underside of the railcar as it flipped over onto its right side during 

the derailment. The rolling assembly was found inside of the railcar. In addition, two more 

passengers were partially ejected out of the opening created by the railcar’s structural breach. 

Another passenger was fatally injured when he was struck by the rolling assembly inside of the 

railcar.

In total there were seven full train passenger ejections and three partial ejections.
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1.13.6 Occupant Space Design and Safety of Railcars

During this derailment, the rail passengers experienced both forward and lateral forces. 

Several passengers sustained serious head and torso injuries during the derailment. A secondary 

collision occurs when the train occupants continue moving at the train’s initial speed while the 

train rapidly decelerates. The impact occurs when an occupant collides with an interior surface, 

such as the seatback in the row ahead. An occupant will survive a collision with an interior surface 

(such as a seat back, wall, or table) during an accident if the forces and accelerations are within 

acceptable human tolerance levels.

Train 501 is not equipped with “occupant restraint systems” used in other forms of 

passenger transportation such as seatbelts or airbags, nor are there any such requirements for 

passenger railcars. These common forms of occupant restraint are found in the airline industry and 

in passenger vehicles but not in passenger trains. The primary strategy for occupant protection in 

passenger trains is “compartmentalization.” This strategy involves attempting to restrict the 

movement of the occupants during a railroad accident to limit the potential for injury.

1.13.6.1 Passenger Seating

Some of the seats in the Talgo Series VI train are designed to rotate which can decrease 

the effectiveness of compartmentalization when the seats rotate during an accident. (See figure 30.) 

In this derailment, investigators observed several seats that had rotated with passengers causing 

injury. To understand the nature of the injuries and why the seat rotation occurred, NTSB 

investigators examined the design.

The release mechanism, located under the side of seat at the aisle, can be manipulated by 

a crewmember by stepping on the latch. The row of seats can be rotated around and locked back 

into position. The rotation of the seats is accomplished by turning the seats starting at one end of 

the railcar and working to the other end. Once the seat has been rotated into place, the locking 

mechanism must be engaged to lock the seat into position and prevent inadvertent rotation.

Figure 30. Coach class seating layout showing rotating and nonrotating seats.

Postaccident interviews revealed that several passengers in AMTK 7423 (9) were injured 

when three rows of seats started to rotate. One passenger was struck in the head with enough force 

to shatter the window. The seat corner of seat 2, which is not designed to rotate, contacted the rear 

bulkhead of the railcar, shattering the glass partition, directly behind the seat. A postaccident
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examination of AMTK 7423 (9) revealed that during the derailment, the metal railing on the 

southside walkway on the overpass penetrated the lower portion of the railcar’s sidewall. This 

resulted in the displacement of the interior sidewall. The three rows of seats were displaced 

laterally causing the seats to rotate. Figure 31 shows the intrusion by the metal railing into the 

railcar and shows the displacement of seats.

Figure 31. Bridge railing penetrating AMTK 7423 and displaced passenger seats.

A passenger in AMTK 7422 (10) reported that a row of seats started to rotate during the 

derailment. This railcar sustained only minor exterior damage and no interior damage. The seats 

were identified as 21/22 and examined. The locking mechanism was found in working order and 

no obvious defects could be found. The locking mechanism appeared not to have been engaged. 

No passenger injuries were associated with the rotation of the seat in this railcar. Seats 1A and 1B 

(nonrotating type) were twisted from the normal positions and seat 4C had rotated in 

AMTK 7554 (4). Although not engaged when investigators examined the locking mechanism 

from 4C, no defects were found.

1.13.6.2 Infant and Child Seating

As discussed above in section 1.13.6, restricting the fore and aft movement or 

compartmentalizing a passenger involved in an accident is effective in minimizing injuries.

Currently there are no features in passenger railcars that allow a parent to secure their child safety 

seat (car seat). In this accident, a family carrying a car seat with an infant boarded train 501 and 

sat in AMTK 7421 (11). The parents reported that they were unaware that the train would not have 

securement straps necessary to belt the car seat into one of the seats in the railcar. Subsequently, 

the car seat containing the child was placed on top of a table during the journey. Just prior to the 

derailment; the father reported that he removed the child from the car seat and entered the lavatory. 

The car seat was left on top of the table. During the derailment, the unrestrained car seat was 

ejected out of AMTK 7421 (11). The car seat was recovered outside near AMTK 7424 (8) near a 

disconnected rolling assembly. (See figure 32.)
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Figure 32. Child car seat near AMTK 7424 (8). (Photo provided by the Federal Bureau of 

Investigation.)

Amtrak’s policy for the transportation of minors aboard their trains is that a child under 

2 years of age and riding for free can use an available seat if it is not needed for a paying passenger. 

If no seat is available, the child is assumed to be carried on the lap of the paying adult. No safety 

provisions are made for smaller children, even if they pay for a seat.

1.13.7 Handicap Accessibility

Train 501 was equipped with two handicap-accessible railcars. One was the Business class, 

AMTK 7554 (4) and one was the Coach class, AMTK 7504 (7). Two wheelchair lifts were 

provided in each railcar, one on each side of the railcar adjacent to the exterior door. In the stowed 

position, the lifts were secured by a metal pin that bolted the wheelchair assembly to the overhead 

frame of the lift and to the floor of the railcar. In AMTK 7554 (4), the right-side wheelchair lift 

was found to be detached from its securement bracket on the floor and pulled away from the top 

by a force exerted on the bottom of the lift at the time of the derailment. The wheelchair lift was 

found partially attached and hanging, obstructing access to the exterior door. On the left side of 

the railcar, the wheelchair lift was still in place. The lift had sustained damage and the securement 

latch had been bent but the lift was still functional. A closer inspection of the wheelchair lift 

assemblies revealed that the structural buckling of the railcar frame allowed the wheelchair lifts to 

be detached from the floor. The weight of the wheelchair lift pulled the top of the lift away from 

the railcar structure. (See figure 33.)
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Figure 33. Exemplar wheelchair lift and damaged lift in AMTK 7554 (4).

A postaccident inspection of AMTK 7504 (7) revealed that both wheelchair lifts were 

missing. Both had broken away from their securement bracket attached to the end of the railcar. 

The right-side wheelchair lift, after detaching from the railcar structure, was propelled through the 

interior of the railcar and breached the exterior wall of the lavatory. After detaching from the 

railcar’s structural support, the left-side wheelchair lift was propelled to the right and toward the 

opposite door at the end of the railcar.

Only one wheelchair lift was recovered from the scene. Components from the second lift 

were recovered. Due to the extensive damage to the railcar and to the recovered wheelchair lift, it 

was not possible to determine which wheelchair lift had been recovered from the debris. Figure 34

shows the interior damage to AMTK 7504 (7) and the location where the wheelchair lifts were 

mounted prior to being torn away from the railcar structure.

Figure 34. Photograph of missing wheelchair lift and damage to AMTK 7504 (7).
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Figure 35 shows the damage resulting from the right-side wheelchair lift being propelled 

into the exterior lavatory wall in the railcar.

Figure 35. Photograph of the interior lavatory damage of AMTK 7504 (7).
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1.13.8 Interior Glass

The Talgo Series VI railcars are equipped with internal glass doors fitted with tempered 

safety glass at the end of each railcar that separates the vestibule from the interior of the passenger 

compartment. The doors slide into place on a runner behind or in front of the last row of seats in 

each railcar. The door is electrically powered. When the electrical power is removed, 20 pounds 

of force is required to manually open the door. A glass partition is also located at one end of each 

railcar. A small utility hammer is provided for passengers to use to break the glass door in the 

event of an emergency. The sign notifying passengers of the presence of the hammer and the 

intended use is not photoluminescent and would not be visible in low or no-light conditions.

Investigators noted the vestibule door in AMTK 7422 (10) was jammed during 

postaccident interior examinations. Reasonable attempts were made by investigators to open the 

door, but it did not move. The utility hammer remained in place. (See figure 36.)
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Figure 36. Jammed vestibule door, AMTK 7422 (10).

Despite being fitted with safety glass, several of these doors shattered during the 

derailment. In AMTK 7421 (11), the door shattered just behind two seated passengers in the front 

row of the railcar. In addition to the glass interior doors, glass partitions are also incorporated into 

the seating interior design for the dining and bistro railcars. These partitions are used to separate 

seating positions and are located directly behind the head of the passenger. Several of these 

partitions shattered during the derailment.

In the overhead luggage bin area, glass dividers are used to partition the space. Several 

broken dividers were found on the floor of the railcars during the postaccident inspection.

1.13.9 Emergency Egress – Lighting and Signage

Current requirements for passenger railcar emergency lighting are outlined in 49 CFR

238.115, “Emergency Lighting.” The final rule for emergency lighting was established in 

November 2013.
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Title 49 CFR 238.115 (a) (1-4) requires that equipment ordered on or after September 8,

2000, or placed into service for the first time on or after September 9, 2002, have batteries for a 

backup power system. However, this equipment was built before the year 2000. The Talgo trainset 

is required to comply with 49 CFR 238.115 (b)(1-2) that states the equipment should comply with 

APTA standard PR-E-S-013-99, Rev. 1, “Standard for Emergency Lighting System Design for 

Passenger Cars,” that requires railcars to have emergency lighting, “powered from either the main 

battery system, or independent power source(s). Each emergency light fixture shall activate 

automatically or be energized continuously for 90 minutes whenever the car is in passenger service 

and normal lighting is not available.”

The final rule stipulates that no later than December 31, 2015, at least 70 percent of each 

railroad’s passenger railcars that were ordered prior to September 8, 2000, and placed in service 

prior to September 9, 2002, comply with the emergency lighting requirements.

In December 2015, Amtrak petitioned the FRA seeking a temporary waiver of compliance 

for the emergency lighting requirements until December 2017. The justification was based on the 

fact that 70 percent of Amtrak’s fleet was placed into service prior to 2002, thus needing 

modification. The trains required a waiver because they did not meet the requirements of 49 CFR 

238.203 or the end strength. In April 2016, the FRA denied the request in the interest of public 

safety.

According to passengers and emergency responders, the separation of the railcars resulted 

in the loss of lighting that hampered both the passengers’ ability to evacuate from the train and the 

first responders’ rescue operation. In this Talgo train, the batteries are in the power railcar in the 

front of the train and the baggage railcar in the rear of the train. Auxiliary batteries are not provided 

for the individual railcars.

After the derailment, most passengers self-extricated. The inability of the crew to 

communicate with the passengers resulted in the passengers having to decide on their own 

initiative whether to evacuate and to determine the safest route of evacuation. Most of the 

passengers reported that they had no contact with the crew after the derailment. The public address 

(PA) system, which is available on the train, would not have been operational because the train 

came apart in this derailment.

This system is normally hard wired and dependent on the train’s electrical system and not 

wireless. Once the railcars detached, the entire train lost both power and signal for the PA system.

Current requirements for passenger railcar markings and instructions for emergency egress 

and rescue access are outlined in 49 CFR 238.125, “Marking and Instructions for Emergency 

Egress and Rescue Access.”33 Specifically, the rule enhances requirements related to the use of 

high performance photoluminescent (HPPL) material, such as a photoluminescent material that is 

capable of emitting light at a very high rate and for an extended period of time, as well as policies 

and procedures for ensuring proper placement and testing of photoluminescent materials. These 

 33 The rule states that, on or after January 28, 2015, emergency signage and markings shall be provided for each 

passenger railcar in accordance with the minimum requirements specified in APTA PR-PS-S-002-98, Rev. 3, 

“Standard for Emergency Signage for Egress/Access of Passenger Rail Equipment,” Authorized October 7, 2007, or 

an alternative standard providing at least an equivalent level of safety, if approved by FRA pursuant to section 238.21.
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revisions are intended to help ensure greater visibility of signage and markings in an emergency 

situation so that train occupants can identify emergency exits and the path to the nearest exit in 

conditions of limited visibility, which include, but are not limited to conditions when all lighting 

fails, or when smoke is present in the passenger railcar.

Existing emergency egress signage inside some passenger compartment areas within 

passenger railcars has been ineffective due to its inability to absorb sufficient levels of ambient or 

electrical light. The requirements in this rule improve the conspicuity of signage and markings in 

the passenger compartment, and thus increase the discernibility of the exit signs and markings.

About 2 years before the derailment, Amtrak performed an internal audit of its inventory 

for compliance with federal regulations. At that time, Amtrak identified several problems with 

their fleet in general and the Talgo trainsets specifically. During testing for emergency lighting 

requirements, Amtrak discovered that the signage in the Talgo railcars lacked the required 

photoluminescence for instructional signs for the operation of emergency door, emergency exit 

signs, and instructional signs for doors and windows. Amtrak also noted that the Talgo trainsets 

did not comply with the federal regulations regarding emergency lighting in the railcar aisles and 

passageways during low-light and no-light operations. Amtrak presented its findings to the local 

Talgo representative.

Talgo started a project on the Talgo Series VI trainsets to:

• Replace the emergency door opening instruction signs with ones compliant with the 

current HPPL requirement

• Replace the retroreflective border around the manual release levers and handles with 

compliant HPPL material

• Increase the illumination in the vestibule to assure the above material is sufficiently 

charged

In January 2019, Talgo had completed replacing the signs. However, the additional work 

to upgrade the emergency lighting is still ongoing as of the date of this report.

1.13.10 Emergency Doors

The instructions to operate the door are located on the bulkhead above the manual release 

lever. It provides step-by-step instructions to the passenger on how to open the emergency door to 

evacuate the train. Because the process to open the doors is not intuitive, instructions are required 

to be placarded.

The instructions advise the user to:

• Press a green button (some signs indicate to wait 5 seconds before going to next 

step). When the main or auxiliary power is available, the door will usually slide 

open which alleviates the need to proceed further with the instructions.
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• (In the event that the door fails to open), pull the red lever. It is made to operate 

in the either up or down position. 

• Pull up on handle. The handle releases the mechanism that is holding the door 

in place.

There was a pictorial and instructions to use two hands to push out and sideways to slide 

the door open. During the postaccident inspection of the railcars, all the placards were found to be 

in place.

However, none of the placards possessed any photoluminescence, which means that in low 

or no-light situations, the signs cannot be seen by passengers attempting to use the door for egress 

in an emergency.

At the end of each railcar in the vestibule area are two exterior doors that provide 

emergency egress. During normal train operation (under power), the train’s electrical system 

releases the door and allows the door to be opened. Under emergency power, the train’s electrical 

system still provides some electrical power to operate the door. In the event that the door does not 

automatically open, the electrical system can provide some assistance to allow the ease of opening 

the door manually.

During the loss of all electrical power, including emergency auxiliary power, the door 

operation is manual only. A loss of the electrical power assist can occur whenever the railcars 

become detached such as in a collision or derailment. The exterior door is of substantial weight 

and even some adults will have difficulty pushing the door open.

During the postaccident inspection, several undamaged doors were selected at random and 

opened. Whereas all the doors could be opened, several issues did arise. In one instance, the red 

lever only worked in the up position, though it was designed to work by either pulling down or 

pushing up to release the manual pull handle. Talgo committed to revising its maintenance 

procedure to assure both directions will perform as intended.

Another issue found with the lever involved the wire ties Talgo used to secure the lever to 

prevent accidental or deliberate tampering. In one case, the wire tie increased the difficulty in 

actuating the lever. Investigators had to use both hands and lean against the handle with their full 

weight to break the wire and move the lever. 

It should be noted that when investigators examined an exemplar undamaged trainset on 

March 7, 2018, at the maintenance facility in Seattle, Washington, similar issues with the 

tampering device hampering door use were found when trying to operate the door release 

mechanism. The issue was communicated to Amtrak and Talgo who committed to look at possible 

improvement. Talgo advised investigators that it is researching alternatives.

In AMTK 7423 (9), two passengers reported that they had attempted to exit the train after 

the derailment but could not get either of the exterior doors to open. An examination of the railcar 

revealed that evidence was present to indicate that someone had attempted to open the door, it was 

clear that not all the proper steps to open the door were performed. The instructional placard was 
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present but did not possess the required photoluminescence by regulation. The derailment occurred 

prior to sunrise. (See figure 37.)

Figure 37. Exemplar emergency door showing instruction placard.

1.13.11 Emergency Windows

Several undamaged windows were found both inside and outside of the railcars. Window 

zip strips were also found inside of several railcars indicating that the emergency windows were 

used for egress after the derailment.34

The exterior windows on each railcar had been marked with a decal indicating the proper 

way to use the window in an emergency. The railcar windows were found to function as designed. 

However, several of the passengers, bystanders, and members of the fire department reported that 

the multiple window markings were confusing. The instruction provided to gain access through 

one window was not the same as the instructions provided to gain access to the adjacent window. 

In several instances, individuals were attempting to gain access through a window incorrectly, 

delaying access to the interior of the railcar and the rescue effort.

 34 A zip strip is a removal gasket that when pulled allows for the rapid removal of a train car window in an 

emergency.
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Figure 38 illustrates the decals found on the exterior of the railcar near windows on the 

Talgo railcars. Instructions to correctly gain access are for the side passenger windows only. 

Figures 38 and 39 also show the instructions for the emergency windows located at the first and 

last windows on each side of the railcars.

Figure 38. Interior emergency window removal instructions.

Figure 39. Interior emergency window removal instructions.

1.14 Emergency Response

The derailment occurred in Pierce County, Washington, about 3 miles north of Thurston 

County. The location was adjacent to JBLM which has concurrent emergency response jurisdictio n

with Pierce County.

1.14.1 Pierce County Emergency Management Agency

The Pierce County Emergency Management Agency (EMA) is a governmental agency that 

responds to all types of hazards, emergency situations, and disasters. The agency’s mission is to 
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prevent, mitigate, respond, and recover from these incidents that occur within Pierce County. The 

Pierce County EMA is accredited by the Emergency Management Accreditation Program, with 

the most recent reaccreditation occurring in 2016. The agency is comprised of six divisio ns: 

Operations, Communications, Preparedness, the Fire Prevention Bureau, the county’s Emergency 

Medical Certification and Recertification programs, and the Washington State Search and Rescue 

Task Force. The agency communications centers operate on a 700 megahertz (MHz) radio 

frequency. Pierce County EMA writes plans and conducts training including mass casualty 

incidents. The agency participates in training seminars and live drills sponsored by Amtrak. In 

addition to training, the agency takes part in regional meetings with other emergency management 

agencies.

On the morning of the derailment, the Pierce County EMA deputy director was notified of 

the derailment about 10 minutes after it occurred and immediately activated its Emergency 

Operations Center. The agency also ensured that Family Assistance Centers were available to 

provide support to the victims and their families during the response.

1.14.2 Fire/Rescue and EMS Response

At the accident location (which was adjacent to the JBLM base), JBLM entered into an 

agreement providing emergency response services to the Pierce County Department of Emergency 

Management. In this shared jurisdiction, JBLM emergency responders conducted operations in 

accordance with the Pierce County Emergency Management Plan, and the Mass Casualty Incident 

(MCI) protocol.35 The protocols outline the treatment and transportation of patients, hospital 

protocols, on-scene operations, accountability, and communications. JBLM staff are certified to 

operate under the direction of the Washington State Medical Director, and the Medical Director 

for the United States Department of Defense (DOD).

On the day of the derailment, JBLM dispatched all six engine companies to the scene at 

7:37 a.m. The time of the accident corresponded with the normal duty shift change at the fire 

department, which resulted in two shifts of firefighter/emergency medical technicians (a total of 

84 firefighters) available to respond to the derailment. In addition to the JBLM engine companies, 

three JBLM chief officers responded to the scene. The responding command officers included the 

assistant chief who assumed the role of the incident commander, an operations chief, and a chief 

officer who acted as the medical safety officer for the response.

The JBLM incident commander requested a mutual aid response and the request was 

forwarded to Thurston County. The assistant chief for the Lacey Fire Department, a department in 

Thurston County, reports that the mutual aid call was received by his agency as a Level 1 MCI. 

The assistant chief advised that given the information he received regarding the nature of the 

accident, he upgraded the Thurston County response to an MCI Level 2. This resulted in the 

response of 45 units with about 100 firefighters to the derailment (which was in Pierce County). 

The Lacey Fire Department assistant chief stated that his goal was to have more units on the way 

to the accident site to minimize the delay in obtaining resources. The decision on whether these 

 35 An MCI Level 1 incident involves between 5-10 people and required local resources and responding agencies. 

An MCI Level 2 incident involves between 10-20 people, requires local resources and responding agencies, and may 

require additional resources from other jurisdictions within the region.
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units would be necessary was to be made at the scene, after conferring with the incident 

commander. The overwhelming number of resources provided by Thurston County resulted in 

Pierce County units not being deployed, despite their availability and proximity to the scene.

Fire/Rescue and emergency medical technician resources were provided by the DuPont 

Fire Department, the West Pierce Fire Department, the Lacey Fire Department, the Olympia Fire 

Department, the Tumwater Fire Department, the Gig Harbor Fire Department, the Central Pierce 

Fire Department, and the South Bay Fire Department. Transport ambulances were provided by the 

county fire departments, and local contractors; American Medical Response, Inc. (AMR) and 

Faulk ambulance services, and Madigan Army Medical Center. 

The victims of the derailment were transported to various hospitals both in Pierce County 

and Thurston County. Some of the victims were transferred to specialized treatment facilities. 

Table 8 outlines the distribution of victims to the various medical treatment facilities. 

Table 8. Distribution of victims to medical facilities.

Hospital Location Trauma Designation Patients

Madigan Army Medical Center DuPont II 16

Providence St. Peter Hospital Olympia IV 9

Good Samaritan Puyallup III 13

MultiCare Allenmore Hospital Tacoma II 5

St. Joseph Medical Center Tacoma II 11

Harborview Medical Center Seattle I *4

Capitol Medical Center Olympia IV 7

Tacoma General Hospital Tacoma II 3

*Transferred to hospital from other facilities.

1.14.3 Law Enforcement Response

The primary law enforcement agency in Pierce County is the Pierce County Sheriff’s 

Department. The closest law enforcement agency adjacent to the derailment site was the Lakewood 

City Police Department. Communications for these and other agencies within Pierce County are

provided by the Emergency Communications Center, known as South Sound 911. WSP has 

primary jurisdiction on I-5. The Washington State Police (WSP) and other agencies in Thurston 

County come under the Thurston County Emergency Communications Center known as 

TComm911.

The recorded time of the derailment was 7:33 a.m. The first eyewitness call reporting the 

derailment was received by the South Sound 911 Communications Center at 7:36 a.m. The WSP

received its first 911 call at 7:38 a.m. The eyewitness reported that he called 911 and his call was 

routed to the Thurston County Emergency Communications Center. The dispatcher then rerouted 

the call to the South Sound 911 Communications Center for Pierce County. Once connected with 

an emergency call taker at South Sound 911, the eyewitness was advised that the center had already 

received multiple calls reporting the derailment. Table 9 shows the timeline of the calls.
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Table 9. Emergency response timeline.

Time Response

7:36:10 First call received by South Sound 911 Emergency Communications Center

7:37:05 Call dispatched to DuPont Police Department (DuPD)

7:37:17 Call dispatched to Steilacoom Police Department(SMPD)

7:37 JBLM Emergency Communications Center notified of derailment

7:38 WSP dispatched to scene.

7:38:30 Lakewood City Police Department (LPD) dispatched to scene.

7:40:30 DuPD arrives on the scene.

7:40:35 Thurston County notified

7:41:54 Thurston County Fire Department responding to the scene. Thurston County law 

enforcement also requested to respond. 

7:44:47 Pierce County Sheriff’s Department (PCSD) dispatched.

7:48:12 SMPD arrives on scene.

7:56:08 DuPont Police Chief assumes command of incident.

7:57 Pierce County Fire Department dispatched to the scene.

8:00 Call for Unified command to be set up at golf course by law enforcement official. Request 

fire department representative

8:01:10 PCSD arrives on scene.

8:01:33 WSP arrives on the scene.

8:07:42 WSP to Command Post to assume control of scene.

8:11 Command Post set up at golf course request for Fire Department representative

8:15:50 Second call for Fire Department representative for “unified” command post at Golf Course.

8:16:01 Fire Captain to respond over to command post at golf course.

9:02:09 Request for OCME Pierce County Medical Examiner to respond to the scene.

Note: JBLM’s arrival to the scene was not recorded by Pierce County Emergency 

Communications Center.

Arriving law enforcement agencies performed traffic control, assisted with the extricatio n 

of the victims, and interviewed witnesses and victims on the scene, at the local hospitals, and at 

the reunification center that was set up at City Hall in the City of DuPont.

In addition to the Pierce County Sheriff’s Department, the City of Lakewood Police 

Department and the WSP, several other police agencies responded to the scene. These included 

the Puyallup Police Department, Bonney Lake Police Department, Federal Way Police 

Department, Steilacoom Police Department, and the DuPont City Police Department. Officers 

from these agencies were part of a joint regional task force. One of the senior command officers 

with the Puyallup Police Department headed the Pierce County Incident Management Team 

(IMT), which responded to the accident. 

1.14.4 Pierce County Incident Management Team

The Pierce County IMT is an integrated team of multidisciplinary professionals of 35-40 

members that include law enforcement, fire/rescue services, emergency management, and other 

county agencies who provide expertise during major incidents to ensure the efficient and effective 

management of the incident. Not every agency within Pierce County has a representative on the 
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team. Once the initial rescue operation had been concluded, the IMT assisted with managing the 

recovery efforts until the scene was cleared.

1.14.5 Fire Department Agencies

JBLM dispatches units through its Emergency Communications Center which receives 

calls from Pierce County. JBLM’s radio communications frequency is not compatible with either 

the Pierce or Thurston County’s radio communication systems.

The lack of interoperability of the JBLM radio communications system with adjacent 

jurisdictions was known before the derailment. About 2 weeks prior to the accident, agencies from 

Pierce County and JBLM participated in a combined training exercise. During that training 

exercise, the participating agencies were unable to “patch” their radio frequencies which should 

have permitted the participants to communicate directly with one another. Shortly after the training 

exercise, the West Pierce Fire Department initiated a plan to mitigate the lack of interoperability 

by stockpiling a cache of portable radios and storing them on a service truck. When dispatched, 

the radios from this truck could be used to equip agencies, like JBLM, with radios to enhance the 

communication capabilities for all the responding units. At the time of the derailment, this resource 

was not used. Few Pierce County Fire Department resources were deployed to the scene due to the 

overwhelming number of Thurston County Fire Department units that had responded, despite the 

proximity of the Pierce County units. A JBLM chief officer advised that his agency possessed 

several Pierce County radios but not in enough quantity for the number of units his agency deploys. 

None of the JBLM chief officers used these radios during the response.

Several of the first responders from Pierce County told NTSB investigators that there was 

not a lot of information received over the Pierce County radio frequency. Responding units were 

not provided basic information as they traveled to the scene. These informational gaps in 

communications included the location of the command post, the identity of the incident 

commander, and the location of the staging area. Because of the lack of communications, many 

first responders reported that they began self-initiated rescue operations which some described as 

“freelancing.” This led to momentary confusion related to the location of personnel and the rescue 

operations that were underway.

The problems encountered with communications resulted in noncompliance with 

established policies and procedures. One of these procedures entailed the accounting of personnel 

on the scene through the Passport Accountability System. Both Pierce County and Thurston 

County Fire/EMS services use the “passport” system or “pass.” “Pass” allows the incident 

command to maintain accurate track and awareness of where resources are committed at an 

incident. The system uses an identification tag that contains a rescuer’s name, company, and unit 

designation. These passes are collected on the scene from each emergency responder and 

maintained by a command officer for personnel safety accountability. 

This personnel safety accountability protocol was not followed on the scene of this 

incident. Several fire company officers reported that they were unable to locate the command post 

or the command officer in charge of personnel accountability to provide their crew’s passports. 

After a period, the officers gave up and none of the passports were given to or collected by anyone 

in charge of the overall accountability of personnel on the scene.
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JBLM advised that due to the size of the incident, it was decided that each unit would be 

responsible for keeping track of their own personnel which is contrary to the design of the passport 

accountability system. Some of the company officers from outside agencies were unaware of the 

change in the protocol and the decision made by the incident commander.

1.14.6 Law Enforcement Agencies

In addition to difficulties with communication between responding Fire/Rescue and EMS 

agencies, the fire departments were unable to communicate with responding law enforcement 

agencies. A separate law enforcement command post was set up away from the interstate in the 

parking lot at the military base golf course. The first arriving law enforcement agency set up this 

second command post to facilitate a larger joint “unified” command with the fire departments and 

law enforcement agencies away from the congestion of the scene. Multiple requests were made 

for a representative from the fire departments to join the command post. In the end, the two 

agencies operated their own individual command posts and did not establish an effective 

communication system between them.

The Pierce County law enforcement agencies were switched over to a common radio 

frequency for communications during the incident. However, Thurston County law enforcement 

agencies that use the TComm911 Center could not communicate with the Pierce County agencies 

without “patching” of radio frequencies, which was not performed. The law enforcement agencies 

noted that both agencies operated on different frequencies which made patching particularly 

difficult.

36

The tracking of police officers on the scene required the ability to communicate with the 

dispatcher by “coming over the air and checking in” or using the computer assisted dispatch (CAD)

system that was part of the county’s communications center.

1.14.7 Training

All the involved agencies participate in yearly training exercises that encompass both mass 

casualty incidents and interagency emergency response scenarios. Both Pierce County and 

Thurston County have a mass casualty incident plan that provides guidance and assistance in the 

coordination of the emergency response between agencies within their county. The State of 

Washington also has a comprehensive emergency management plan for the entire state. These 

plans incorporate four core elements: EMS protocols, command structure, communications, and 

asset management (PCEMS 2019). JBLM conducts training exercises with various emergency 

response agencies within Pierce County.

In addition to local and state government sponsored training, BNSF and Amtrak provide a 

variety of training opportunities in rail emergencies for state and local governments, first 

responders, hospital and medical care providers, and other transit agencies. In August 2017, 

Amtrak sponsored an MCI-train derailment exercise that was attended by individuals from various 

fire and police departments, local government agencies, a local hospital and the communicatio ns 

 36 The agencies unsuccessfully tried patching during a drill 2 weeks before the accident. This experience led the 

command to believe that taking the time to attempt to patch the frequencies would be a waste of time and resources. 
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center in Pierce County. Representatives from the local transit agency and Sound Transit also 

attended the training. The exercise consisted of two parts, with the classroom portion held at the 

Camp Murray National Guard base. The “hands on” training class was scheduled to be held in 

January 2018.

1.14.8 Postaccident Action

Each of the agencies that responded to the derailment participated in a postaccident

critique. These critiques were sponsored by Amtrak and the local government agencies involved.

One of the lessons learned was the failure in the communication system. The deputy 

director of JBLM Directorate of Emergency Services advised that the location where the 

derailment occurred is jointly owned by both the state and federal governments. Both the state and 

JBLM provide fire/rescue and police services to the area. By United States Federal 

Communications Commission regulation, DOD agency radios operate on the 450 MHz range. 

State and local law enforcement and fire/rescue agencies operate on the 700-800 MHz band. The 

communication systems are not compatible. Additionally, the incompatibility creates a problem 

whenever attempts are made to “patch” the two radio frequencies together during a major incident. 

To resolve the interoperability issues, DOD is currently purchasing new Tri-band radios. 

These radios will permit DOD assets, such as JBLM, to program into the radio the frequencies 

required to enable communications between state and federal agencies during interjurisdictio nal 

operations. This will permit a more efficient communication stream between JBLM, Pierce 

County, and Thurston County emergency responders. JBLM advised that the new radios will also 

correct a secondary issue involving the disruption in communications caused by the lack of a 

“repeater” at the southern end of the military base. The radio communications would be routed 

through the communications centers, such as South Sound 911, alleviating the need to “patch” into 

the various frequencies. Until the deployment of the new radios is completed, JBLM will maintain 

its current protocol for the establishment of a “unified command”. The protocol requires that the 

chief officers of the various agencies be in one centralized location so that information is shared 

in a timely manner.

1.15 Track and Structure

The 136-pound continuous welded rail in the curve was supported with wooden crossties

spaced 19.5-inches apart (center of crosstie to center of adjacent crosstie). The rails were supported 

by concrete crossties where the track was straight. The rails were sitting on 7 3/4-inch x 16-inch 

Pandrol tie plates. The rails are fastened to the crossties through the tie plates with elastic type

fasteners (McKay on concrete; Pandrol e-clips on wood) to hold the rail in place and retard

longitudinal rail movement. Near the curve and tangent track preceding the curve, every crosstie

was “box” anchored.37 Investigators did not observe any unintentional rail movement near the 

accident site.

 37 Box anchored means that each rail has two anchors placed on each side of the crosstie to restrict longitudinal 

rail movement.
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Sound Transit inspected and maintained the Lakewood Subdivision main track as Class 4 

track according to federal standards.

38 This allowed passenger trains a maximum speed of 80 mph 

on the tangent (straight) sections of track, although an additional regulation limited the maximum 

speed to 79 mph.

1.15.1 Inspections

Investigators examined the records for required track inspections, internal rail tests, and 

track geometry tests. None of the results from these examinations were noteworthy and those that 

were required by regulation were performed within standard.

1.15.2 Curve and Signage

Sound Transit identified the permanent speed restrictions for the Lakewood Subdivisio n

in Timetable No. 2, which went into effect on November 13, 2017.39 All operating crews were 

required to use the timetable when operating on the subdivision.

The maximum authorized speed for passenger trains on the Lakewood Subdivision was 

79 mph. At MP 19.8, there was a 30-mph speed restriction for the sharp curve.40 There was a sign 

at MP 19.8 to indicate the speed restriction. Two miles before reaching the curve, at MP 17.8, there 

were advance warning speed signs of the upcoming speed restriction. The signs “T-30” and “P30” alerted Talgo (T) and passenger (P) operating crews that a 30-mph speed restriction entering 

the curve was 2 miles ahead. The advance warning signs have yellow backgrounds and black letters 

and/or numbers, except signs for Talgo operations have black backgrounds and yellow letters and 

numbers. (See figures 40 and 41.)

 38 Title 49 CFR Part 213, “Track Safety Standards.”

39 The timetable was prepared by BNSF (the former owner of the Lakewood Subdivision) for Sound Transit.

40 The curve was an 8° 22-minute curve.
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Figure 40. Two-mile advance warning speed sign at MP 17.8- 30 mph.
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Figure 41. Speed restriction sign at entrance to curve MP 19.8 - 30 mph.

Sound Transit had adopted the BNSF’s (former owner of the Lakewood Subdivisio n) 

standard plan for the display of signs. The following were the instructions for the placement of 

advance warnings of a speed restriction:

Advance warning signs as far as feasible [are] located two miles in advance of a

lower speed sign [o]n those lines where both freight and passenger trains operate...

1.16 Signal and Train Control

The Lakewood Subdivision was 20.7 miles of centralized traffic control (CTC) signalized 

territory owned by Sound Transit and dispatched by BNSF in Fort Worth, Texas.41 About 5 miles 

of the subdivision was multiple main, however, it was single main train at the accident location. 

There are 21 public highway grade crossings and 1 private crossing. The public highway grade 

crossings were protected with gates and lights.

 41 Train movements in CTC are authorized by signal indication controlled by a train dispatcher at a remote 

location.
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1.16.1 Positive Train Control

Sound Transit was in the process of installing positive train control (PTC) on the Lakewood 

Subdivision. There are three primary projects associated with activating PTC: (1) wayside 

hardware and communication, (2) locomotive hardware (this also includes training operating 

employees), and (3) an overall communication network between locomotives, wayside, and the 

train dispatching “back office.” Sound Transit had completed the first two of these projects and 

was working with BNSF on the coordination with the train dispatching system when the accident 

occurred.
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2.Analysis

2.1 Introduction

The locomotive engineer of train 501 had been a certified engineer for nearly 4 years, and 

the conductor qualifying on the territory had been a qualified conductor for nearly 6 years. Both 

had maintained regular work and rest schedules on the days leading up to the accident, and there 

was no evidence that either had suffered from fatigue. The engineer was successfully being treated 

for OSA, type-2 diabetes, hypertension, and high cholesterol. The conductor was in good health. 

Neither was impaired by drugs or alcohol, and neither was using a cell phone or other personal 

electronic device while operating the train. Neither had previous disciplinary actions. They were 

not distracted by problems with the passengers. At the time of the accident, there was slight 

precipitation and it was generally dark outside. 

The locomotive and the passenger railcars passed postaccident mechanical inspections. A 

review of preaccident testing did not reveal any functional defects.

Investigators examined the records for track and signal inspections and maintenance. The 

undamaged track was examined during the on-scene investigation. The track and signal system 

were inspected and maintained within regulatory standards, and no track or signal anomalies were 

discovered after the derailment.

The NTSB concludes that none of the following was a factor in this accident: the 

mechanical readiness of the train, the condition of the track or signal system, the weather, cell 

phone use, medical conditions of the Amtrak engineer, use of alcohol or other drugs, fatigue, or 

any impairment or distraction.

2.2 Inward-Facing Audio and Image Recorders

The Charger locomotive was equipped with an inward-facing image recorder that provided 

investigators with both a visual and audio recording of the crewmember activities during the 

accident trip. Amtrak installed these devices even though they are not required by the FRA.

The NTSB has determined that dozens of previous railroad accident investigations would 

have benefitted from this technology. In a number of these accidents, the operator was killed, 

seriously injured, or could not recall details moments before the accident. However, even in the 

cases where the operator was not injured, audio and image recorders could be used to help verify 

what might have been seen and what actions were taken during the accident sequence.

For instance, inward-facing cameras were beneficial in recent accident investigatio ns, 

including the January 4, 2017, collision of two Southeastern Pennsylvania Transportatio n 

Authority trolleys in Philadelphia, Pennsylvania, and the April 3, 2016, Amtrak accident in 

Chester, Pennsylvania (NTSB 2018) (NTSB 2017). In those accidents, as well as this one, 

investigators used the image recordings to gather additional pertinent information about the entire 

accident sequence and used the audio recordings to corroborate the statements made by the 

operating crews. In turn, this information was used to develop recommendations to improve the 
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safety of train operations. These types of recorders are also critical to improving operational safety 

and management oversight.

Unfortunately, in many other railroad accidents, the NTSB has not been able to determine 

the actions of the crewmembers operating the train due to the lack of inward-facing image and 

audio recordings. For instance, in the April 28, 2015, accident involving a Southwestern Railroad 

train in Roswell, New Mexico, a member of the train crew was under the influence of marijuana 

(NTSB 2018a). However, the absence of image and audio recordings prevented the NTSB from 

determining the actions of the crewmembers leading up to the accident. 

The NTSB had similar issues when investigating the September 12, 2008, accident in 

Chatsworth, California (NTSB 2010). The NTSB was unable to determine the actions of the 

Metrolink engineer leading up to the collision and after discovering some illicit activities by the 

engineer during previous trips. The NTSB realized that the railroad had no way of monitoring the 

engineer’s activities to ensure appropriate behaviors. This accident, in which 25 people were killed 

and 102 people were injured, underscored the importance of understanding the activities of 

crewmembers in the time leading up to the accident. As a result of that investigation, the NTSB 

made the following safety recommendations to the FRA: 

Require the installation, in all controlling locomotive cabs and cab car operating 

compartments, of crash- and fire-protected inward- and outward-facing audio and 

image recorders capable of providing recordings to verify that train crew actions 

are in accordance with rules and procedures that are essential to safety as well as 

train conditions. The devices should have a minimum 12-hour continuous recording 

capability with recordings that are easily accessible for review, with appropriate 

limitations on public release, for the investigation of accidents or for use by 

management in carrying out efficiency testing and systemwide performance 

monitoring programs. (R-10-1)

Require that railroads regularly review and use in-cab audio and image recordings 

(with appropriate limitations on public release), in conjunction with other 

performance data, to verify that train crew actions are in accordance with rules and 

procedures that are essential to safety. (R-10-2)

The NTSB reiterated these recommendations following the May 12, 2015, derailment of 

an Amtrak passenger train in Philadelphia, Pennsylvania, in which 8 passengers died and over 

200 passengers were injured (NTSB 2016). At the time, the FRA said that it had begun the process 

of issuing a notice of proposed rulemaking mandating the installation of inward- and 

outward-facing audio and image recorders in the controlling locomotive cab and cab car operating 

compartments.

The NTSB continues to believe that inward- and outward-facing audio and image recorders 

improve the quality of accident investigations and provide the opportunity for proactive steps by 

railroad management and the FRA to improve operational safety. Consequently, in the Roswell 

accident, the NTSB again reiterated Safety Recommendation R-10-1 and 
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Safety Recommendation R-10-2 to the FRA.42 The current status of those recommendations is 

“Open⸻Acceptable Response.”

The NTSB is also aware that, not later than 2 years after the date of FAST Act, the Secretary 

of Transportation shall promulgate regulations to require each railroad carrier that provides 

regularly scheduled intercity rail passenger or commuter rail passenger transportation to the public 

to install inward- and outward-facing image recording devices in all controlling locomotive cabs 

and cab car operating compartments in such passenger trains. This rulemaking required the 

installation of inward- and outward-facing locomotive image recorders on controlling locomotives 

of passenger trains. The recordings would be used to help determine the cause of railroad accidents 

and to prevent similar accidents.

The NTSB notes that the FAST Act does not require in-cab audio. The NTSB believes that 

both image and audio recording devices are needed to conduct comprehensive accident 

investigations. Regardless, the FRA has not developed regulations requiring the installation of any 

recording devices in intercity rail passenger or commuter passenger transportation, despite the 

passing of the 2-year deadline. 

The NTSB concludes that this accident has demonstrated the value of image and audio data 

for the accident investigation and development of safety recommendations. Nonetheless, after six 

reiterations of the NTSB’s Safety Recommendation R-10-01, the FRA has not taken positive 

action regarding inward-facing devices nor developed inward-facing recorder regulatio ns 

discussed in the FAST Act. Therefore, the NTSB concludes that the FRA has demonstrated an 

unwillingness to implement the recommendations and regulation that would require inward-facing 

video and audio devices that are critical to accident investigations and improving safety on our 

nation’s railroads. Further, the NTSB concludes that inward-facing recorders with both image and 

audio capabilities can increase the understanding of the circumstances of an accident, and, 

ultimately, provide greater precision in safety recommendations and subsequent safety 

improvements. Therefore, the NTSB recommends that the United States Secretary of 

Transportation require the FRA to comply with the FAST Act and issue regulations for 

inward-facing recorder regulations that include audio recordings as recommended by NTSB in 

Safety Recommendations R-10-01 and R-10-02.

2.3 Positive Train Control

At the time of the accident, BNSF, Amtrak, and Sound Transit were still working on the 

installation, testing and verification, and validation of the PTC system. PTC, as mandated by 

Congress, must be designed to prevent train-to-train collisions; derailments caused by excessive 

speed; unauthorized incursions by trains onto sections of track where maintenance activities are 

taking place; and the movement of a train through a track switch left in the wrong position. Since 

installation and testing was not complete, the PTC system was not in operation at the time of the 

accident.

 42 At the time of the accident, Southwestern Railroad had a lease with BNSF to operate trains and maintain the 

track from Clovis, New Mexico, to Carlsbad, New Mexico. However, since then, BNSF has terminated the lease and 

currently operates this track with its own personnel and equipment.
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The NTSB recognizes that had PTC been operational, the engineer would have been 

notified of his location and speed in the cab. With PTC, a screen displays the train’s location to 

the engineer and warns of an upcoming speed reduction. If the engineer does not respond 

appropriately to the speed reduction, PTC will stop the train. Therefore, the NTSB concludes that 

had the PTC system been fully installed and operational at the time of the accident, it would have 

intervened to stop train prior to the curve, thus preventing the accident. 

2.4 Human Performance

The engineer of train 501 qualified on the Point Defiance Bypass 2 days before the accident 

occurred. The accident trip was his first time operating on the territory in revenue service and 

without supervision. He was accompanied in the operating compartment by a qualifying conductor 

who was making his first trip over that territory. The engineer’s qualification training included a 

number of observation rides, then making two northbound and one southbound trips while 

operating the train under supervision of a road foreman. Some of these trips were made on the 

Charger locomotive, the type of lead locomotive involved in the accident. The engineer was aware 

of the 30-mph curve at MP 19.8. On the morning of the accident the road foreman phoned the 

engineer and recalled saying “remember the curve, slow down early, take your time, be careful.” 

However, while traversing the territory, the engineer missed key wayside milepost signs and 

ultimately was surprised that he had reached the curve in an overspeed state.

During the review of the inward-facing cab video and audio, investigators determined that 

the brief conversations between the engineer and the conductor during the trip did not distract them 

from their operational duties or hamper their ability to identify wayside signs. During the time the 

engineer missed signs between MP 18 and MP 19, he was looking ahead and not engaged in 

conversation. Moreover, the crew’s brief exchange after MP 19 was halted when the overspeed 

alarm was activated, which allowed the engineer to assess the situation without interference.

Local Amtrak supervisors and a BLET local chairman did not believe that the physical 

characteristics of a territory was particularly difficult to learn. They recognized that the 30-mph 

curve at MP 19.8 posed the greatest potential hazard and believed that their training on the physical 

characteristics of the territory provided engineers with the necessary skills to operate a train safely 

over the new territory. They also believed that the training on the Charger locomotive that occurred 

before the inaugural operations on the Point Defiance Bypass was adequate. The NTSB, however,

is concerned that engineers operating on the new Point Defiance Bypass territory needed additional 

competency in both the features of the Charger locomotive and the physical characteristics of the 

territory. Typically, engineers qualify on territories while operating locomotives with which they 

are familiar. Their proficiency with the locomotive allows them to focus on the details of the 

territory without having to also learn the particulars of the equipment. In this accident, however, 

the engineer only had rudimentary knowledge and experience with both the Charger locomotive 

and the physical characteristics of the territory. He may not have developed the necessary 

competency to manage ambiguous situations – such as unfamiliar locomotive alarms while 

concurrently maintaining a vigilant watch on the territory being traversed. To understand this,

NTSB investigators examined the Amtrak engineer’s training on both the territory and the 

equipment to operate safely in all conditions.
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2.4.1 Qualification Trips on the Territory

Amtrak supervisors developed the training needed to qualify operating crews on the 

physical characteristics of the Lakewood Subdivision. While some Amtrak officials mentioned 

that they would have preferred additional training time (to expose crews to both daytime and 

nighttime operations, for example), they believed that the number of observation rides and actual 

throttle time provided was sufficient. Both the Amtrak engineer and the road foreman of engines 

(Amtrak supervisor at Seattle) overseeing the engineer’s qualification runs believed that the 

qualification training was adequate. 

The Amtrak engineer was aware of the curve at MP 19.8 and the 30-mph speed restrictio n. 

As he operated over the territory toward that curve, he relied on MP signs to help him identify his 

location. He had successfully identified MP 16 and MP 17. He did not recall seeing the advanced 

warning speed reduction sign at MP 17.8, which is 2 miles from the curve at MP 19.8. While this 

sign is significant to freight operations that initiate braking at this location, it did not have 

operational relevance for the Amtrak engineer whose strategy was to initiate braking about one 

mile from the curve. However, he did not see the sign at MP 18, despite not being distracted by or 

engaged in another task as he approached that sign.43 He also did not see the sign at the signal at 

MP 18.8, the location where he planned to initiate braking. Investigators noted, however, that this 

sign was highly inconspicuous because it blended in with the signal box directly behind it.

The Amtrak engineer, on other territories where he had considerable experience, used 

stationary objects such as bridges, buildings, siding switches, and signals as cues of his location. 

Such external cues are typically developed over time as operating crews become more familiar 

with the territory. On the Lakewood Subdivision, a potential landmark could have been the I-5 

overpass between MP 18 and MP 18.8. However, because of his minimal exposure with the 

territory, one operating trip in the dark in the southbound direction, the engineer had not 

established or used wayside landmarks to help him identify his location. 

As previously discussed, the Amtrak engineer passed, on the first attempt, his written exam 

on the physical characteristics of the territory which included a question about the curve at 

MP 19.8. While the examination contained questions about signage, it did not include questions 

regarding the use of landmarks that could aid the crew in identifying the train’s location. Operating 

crews with limited experience on a territory rely more heavily on wayside signage, and those who 

fail to see the wayside signs are more prone to misidentify their location. Without the use of 

landmarks, the Amtrak engineer did not recognize that he had passed the signs at MP 18 and 

MP 18.8. Consequently, he initially misidentified the signal entering the curve at MP 19.8 as being 

the signal at MP 18.8.

The NTSB concludes that the Amtrak qualification program for the Point Defiance Bypass 

did not effectively train and test qualifying crewmembers on the physical characteristics of a new 

territory. Therefore, the NTSB recommends that Amtrak ensure operating crewmembers 

demonstrate their proficiency on the physical characteristics of a territory by using all resources 

 43 It is unclear if background lights from the highway affected his vision.
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available to them, including: in-cab instruments, signage, signals, and landmarks; under daylight 

and nighttime conditions; and during observation rides, throttle time, and written examinations.

2.4.2 Training on the Equipment

The Amtrak engineer participated in group training for the Charger locomotive several 

months before his first trip. This involved classroom instruction, as well as exposure to the 

operating compartment and familiarization with the display screens and controls. The engineers, 

however, did not have the opportunity to operate the Charger locomotive during that initial training 

period. Moreover, during the qualification process, the observation rides and time spent operating 

the train were only occasionally performed on the Charger locomotive. This limited their 

opportunity to experience all elements of the controls, including the audio and visual alerts/alarms, 

as well as the operating consequences associated with those alarm. Specifically, the engineer had 

not seen or heard the alarm associated with an overspeed situation, nor practiced the appropriate 

response for an overspeed alarm. 

The engineer noted to investigators that because this was his first “solo” trip in the 

locomotive, he wanted to “sit in the seat, ... familiarize myself with the position of the gauges and 

what they were going to tell me,” however, the engineer further stated that he was unable to do 

this due to the mechanics of continued troubleshooting of the train. Based on his statement to 

investigators, the engineer did not have as much time as he would have liked to familiarize himself 

with the new locomotive just prior to picking up passengers at the Seattle King Street Station.

In this accident, the engineer said many times he was unfamiliar with the overspeed alarm 

in the Charger locomotive. Investigators were able to determine that the locomotive was 

manufactured to meet AAR specification M-591, Locomotive System Integration Operating 

Display (2010). The standardization of locomotive alarms and controls is recognized as a benefit 

to all train crews. This standard applies to all new road locomotives equipped with electronics 

ordered after January 1, 2008. The scope of this standard states the following:

This document defines the basic requirements for an industry standard visual 

display of locomotive operating information. This display is a part of the user 

interface between the operator and the integrated cab electronics environment. It is 

intended that the specification of these items will define a display concept that 

achieves a level of standardization while allowing enough flexibility to encourage 

innovation and accommodating unique railroad requirements.

AAR Standard M-591 defines location, size, text, color, audio (when required), and priority 

for each standard critical warning alarm that would include overspeed alarms.

Early into the accident trip, the engineer told the conductor that this was a learning 

experience for him, including what throttle position he needed to use to maintain speed. He made 

all station stops without incident. However, while operating over the portion of the territory on 

which he had experience, his train exceeded the temporary restricted speed by about 10 mph. It is 

unclear if that was the result of him being unaware of the speed restriction or if he mismanaged 

the train’s speed.
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The mile of track leading up to the accident curve was a critical portion of the trip. The 

engineer had planned to use the sign at MP 18.8 as his cue to initiate braking to slow the train for 

the MP 19.8 curve 1 mile away. However, he missed that sign and did not slow the train when he 

passed that area. He continued to look forward and outside the front windshield.

Just over 1/2-mile (and about 27 seconds) from the accident curve, with the train traveling 

at 82 mph, the engineer heard a series of double beeps, saw flashing text on one screen, and saw 

illuminated lights on another screen. His focus then shifted from outside the train to the inside as 

he analyzed the audible and visual alarms that he had not previously experienced on this 

locomotive. Specifically, he spent most of the next 20 seconds looking at the screens on the control 

panel, trying to understand the meaning and implications of the alerts. During this period, he briefly 

looked up and saw the signal at MP 19.8, but initially believed that was the signal at MP 18.8. He 

then returned his gaze to the control screens and finally recognized that he had tripped the 

overspeed alarm. However, this recognition occurred only about 5 seconds before the train reached 

the curve.

For an extended period, the engineer was unclear about the meaning of the audible and 

visual alerts and the relevance to train operations. His prolonged attention on the control screens, 

at the expense of looking outside the cab, minimized his opportunity to scan the territory and 

identify his location or potential hazards. Moreover, his focus on the alarms likely affected his 

sense of the time and distance his train had traveled. Consequently, he was unaware that he was 

nearing the curve in the moments prior to the accident. If the engineer had been familiar with the 

overspeed alarm, he likely would have spent less time managing the alarm and maintained greater 

vigilance outside the locomotive. Therefore, the NTSB concludes that Amtrak did not provide 

sufficient training on all characteristics of the Charger locomotive. The NTSB further concludes 

that the engineer’s unfamiliarity with, and fixation on, the audible and visual alerts associated with 

the overspeed alarm reduced his vigilance of events outside the locomotive moments before the 

accident. Therefore, the NTSB recommends that Amtrak revise its classroom and road training 

program to ensure that operating crews fully understand all locomotive operating characteristics, 

alarms, and the appropriate response to abnormal conditions.

Amtrak’s locomotive engineer training program for the northeast corridor effectively uses 

train simulators to help familiarize trainees on locomotives and on the territory where they operate. 

Simulator training provides trainees with the opportunity to experience and respond to a wider 

range of events over a shorter period of time. However, Amtrak has not initiated widespread use 

of simulator training, particularly with engineers operating new or unfamiliar equipment. The 

NTSB concludes that engineers could better master the characteristics of a new locomotive or 

territory with the use of simulators. Therefore, the NTSB recommends that Amtrak require that all 

engineers undergo simulator training before operating new or unfamiliar equipment (at a 

minimum, experience and respond properly to all alarms), and when possible, undergo simulator 

training before operating in revenue service in a new territory and experience normal and abnormal 

conditions on that territory.

2.4.3 Developing Training Programs

This accident illustrated that external challenges (such as operating on a new territory) can 

adversely interact with internal demands (such as operating a new locomotive with unique alarms 
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and displays, or with new crewmembers) and affect safe train operations. These factors must be 

considered when developing an effective training and qualification program. Rather than relying 

primarily on subjective measures or individual experiences to develop a training program, a task 

analysis can objectively identify the skills required for safe operations. A task analysis is the 

systematic identification of the fundamental elements of the tasks comprising a job, and the 

examination of the knowledge and skills required for successfully completing the job. This 

information can be used to develop training programs and evaluation tools.

An FRA report recognizes cognitive tasks analysis (CTA) as a means to “identify and take 

into account the cognitive requirements inherent in performing complex work” such as operating 

a train (FRA 2013). The report further states:

Cognitive task analysis methods provide a means to explicitly identify the 

knowledge and mental processing demands of cognitive work (e.g., what 

knowledge and skills people need to learn to do the job; what things they need to 

attend to and what mental calculations they must make to perform a task). CTA 

methods also provide a means to identify the kinds of errors that workers are prone 

to and the factors that contribute to those errors (e.g., confusable displays, high 

workload, lack of understanding of how the technology works).44

Amtrak used subjective evaluations in lieu of objective criteria to determine if employees 

were qualified on the Point Defiance Bypass. There was no written evidence that Amtrak had 

developed a task analysis of the skills necessary to safely operate on the bypass. Further, Amtrak 

had no objective performance criteria to evaluate operating employees on their ability to operate 

safely on the new territory. The NTSB concludes that a systematic approach to training would 

have aided Amtrak managers in recognizing the challenge of operating new equipment on new 

territories. Therefore, the NTSB recommends that Amtrak implement a formal, systematic 

approach to developing training and qualification programs to identify the most effective strategies 

for preparing crewmembers to safely operate new equipment on new territories. 

2.4.4 Advance Warning Speed Reduction Signs

Investigators noted advance warning speed reduction signs (“T-30” and “P-30”) on the 

Point Defiance Bypass at MP 17.8 alerting Talgo (T) and passenger (P) operating crews that a 

30-mph speed restriction entering the curve was 2 miles ahead. The BNSF rulebook (that applied 

to the bypass) specified that the advance warning sign will be placed 2 miles in advance of the

location where the lower speed takes effect. This location may be based on several factors, 

including the braking distances for freight trains, which may require 2 miles to safely slow the 

train. On the Point Defiance Bypass, this rule applied to Talgo and passenger trains when there 

was an upcoming significant speed reduction requirement.45 The rulebook also indicates that a 

sign repeating the permissible speed be placed at the point where the reduced speed applied (such 

 44 As discussed in this report, the potential errors presented in the FRA study occurred in the DuPont accident. 

45 There was not an advance warning sign for freight trains at this location because freight trains were already 

operating at a slower speed.
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as at the entrance of a curve). Investigators noted that there was no additional signage indicating a 

speed reduction until the entrance of the curve.

The BLET local chairman stated that while operating crews do not normally use advanced 

warning signs, they are important to use in a new territory. The Amtrak engineer did not recall 

observing the advance warning sign at MP 17.8, in part, because it was located too far in advance 

of the curve for him to be concerned about slowing down at that point. An Amtrak official 

suggested that the advance warning signs may have immediate significance for freight trains who 

initiate braking about 2 miles before the curve but have less benefit for passenger operations, who 

typically begin braking about 1 mile before reaching the curve. 

Advance warning signs provide an added layer of safety for operating crews, particularly 

those who are new to the territory. The NTSB, however, contends that a single sign installed 

2 miles from a speed reduction may not provide equal and optimal levels of safety for freight, 

Talgo, and passenger train crews. For instance, an operating crew of the freight train may use the 

advance warning sign as a cue to immediately begin braking. However, because he had no need to 

initiate braking at that location, the Amtrak engineer paid little attention to that sign because it did 

not immediately affect his train operations.

Human factors research has found that effective warnings must initially attract attention 

and stand out from the background (such as be salient or conspicuous) particularly in cluttered 

environments where other stimuli compete for their attention (Wogalter and Laughery 1996). 

Thus, consideration must be given to the design of warning signs, including its shape, print size, 

color, contrast to the background, location (both spatial and temporal), illumination, and passive 

vs. active (for instance, flashing) to enhance their saliency. 

The highway industry uses warning signs to alert drivers of an upcoming speed reduction. 

Supplemental warning plaques may be used in combination with warning signs when road 

engineering assessments reveal that drivers require additional warning information beyond that 

contained in the main message of the warning sign. These supplemental plaques include distance 

ahead plaques, which may be used to inform drivers of the distance to the condition indicated by 

the warning sign. For example, the distance ahead plaques may display “2 MILES”, “1 MILE”, 

and “500 FEET.”

In this accident, the Amtrak engineer may have benefited from supplemental warning 

plaques closer to the curve. Supplemental warning plaques strategically installed between MP 17.8 

and the curve at MP 19.8 (for instance, at or near MP 18.8 where he planned to initiate braking) 

may have aided the Amtrak engineer in identifying his location and prompted him to begin slowing 

his train for the upcoming 30-mph curve. The NTSB concludes that supplemental warning plaques, 

such as distance ahead plaques, or other types of conspicuous signs strategically positioned after 

an advance warning speed reduction sign would provide enhanced visibility as an added level of 

safety for operating crews of passenger and freight trains. Therefore, the NTSB recommends that 

Amtrak work with host railroads and states that own infrastructure over which you operate to 

conduct a comprehensive assessment of the territories to ensure that necessary wayside signs and 

plaques are identified, highly conspicuous, and strategically located to provide operating crews the 

information needed to safely operate their trains. Additionally, the NTSB recommends that the 
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FRA study the efficacy of how signs used in other modes of transportation may be effectively used 

in the railroad industry.

2.4.5 Qualifying Conductor Role and Responsibilities

Conductors and locomotive engineers jointly contribute to the set of cognitive activities 

required to operate the train safely and efficiently. Conductors not only serve as a “second pair of 

eyes,” alerting the locomotive engineer to upcoming signals and potential hazards (such as activity 

at grade crossings or people working on or about the track), they also contribute knowledge and 

decision-making to the locomotive engineer when the crew is faced with challenging situatio ns

(Rosenhand, Roth, and Multer 2012).

The Amtrak engineer and qualifying conductor called out signals on the accident trip. But 

each crewmember believed that the qualifying conductor, who had no familiarity with the territory, 

had little responsibility beyond that. The qualifying conductor used this trip to familiarize himself 

with the territory, and mostly took a passive role in train operations. Amtrak officials believed that 

qualifying conductors riding on the head end could have a greater role in train operations, includ ing 

calling out signals and restrictions, and helping with radio communications. The NTSB also 

recognizes that the qualifying conductor had not previously traversed the Point Defiance Bypass, 

and consequently, would not have been expected to perform all the duties of a conductor qualified 

on the territory. 

Investigators, however, considered if all crewmembers, even those unqualified on a 

territory, could potentially perform a critical role in establishing safe train operations. The Amtrak 

engineer, though qualified, had minimal experience on the territory. The qualifying conductor 

knew that this was the engineer’s first revenue trip on the new territory, and early in the trip the 

engineer told him that he was still becoming familiar with the locomotive. Given these 

circumstances, the NTSB suggests that a qualifying conductor could have had an even greater role 

in establishing and maintaining safe operations. For instance, a qualifying conductor could have 

assisted the engineer in identifying critical signs, such as MP 18.8, where the engineer planned to 

initiate braking for the upcoming curve. Moments before the accident the engineer experienced 

some confusion, became fixated on the computer control displays, and was not looking outside the 

locomotive cab on a continuous basis. A crewmember trained in Crew Resource Management 

(CRM) principles may have recognized these behaviors as clues that an error chain is in progress 

that may lead to an accident and expressed his concerns to the engineer (Adelsohn 2019).

46

Amtrak’s CRM program acknowledges the importance of recognizing deteriorating situations, and 

the need to act to prevent accidents. At the very least, a qualifying crewmember could have taken 

 46 (a) New Amtrak hires receive CRM training once at Amtrak’s training center in Wilmington, Delaware, or 

attending a new hire class in the field. All other transportation employees are scheduled annually during recurrent 

training. (b) One concept in human error is the error chain, that suggests in each accident there are a series of errors 

that link together to form the error chain that is not broken in time to prevent the accident. However, if one link of the 

chain were broken, the accident would not occur. 
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a more active role in maintaining vigilance outside and detecting potential hazards ahead, 

including the upcoming curve.47

Moreover, Amtrak’s CRM program recognizes the impediments to teamwork and 

communication, such as compartmentalizing jobs or duties, and how junior crewmembers could 

provide valuable input. In this accident, the NTSB understands that the qualifying conductor 

perceived his trip as a learning experience, and the Board does not believe that his performance 

was unexpected. The NTSB, however, suggests that qualifying crewmembers, if effectively used, 

can be valuable assets to train operations. The NTSB concludes that crewmembers qualifying on 

a territory can and should play an active role in establishing and maintaining safe train operations. 

Consequently, the NTSB recommends that Amtrak conduct training that specifies and reinforces 

how each crewmember, including those who have not received their certifications or 

qualifications, may be used as a resource to assist in establishing and maintaining safe train 

operations.

2.5 Preparation for Inaugural Cascades Service on Bypass

2.5.1 Multiple Agency/Organization Coordination

The preparation for the inaugural run of the Cascades service on the Point Defiance Bypass 

was complex since it involved coordination between Sound Transit, WSDOT, Amtrak, and the 

FRA over a new section of track that was not outfitted with PTC. Each organization had critical 

roles in ensuring safe operation of the new service. 

However, the NTSB’s review of the coordination between these organizations shows 

inconsistencies and lack of defined responsibilities. Investigators found that not every agency was 

represented consistently during all the preparation meetings. During interviews with agency 

representatives, and from the evidence provided at the NTSB investigative hearing, it was evident 

that the responsibility of each agency was unclear. During the NTSB investigative hearing on this 

accident, Member Earl Weener asked the following question to management representatives from 

the agencies involved in the Point Defiance Bypass Project:

Then we come to the one that confused me, the design responsibility, in particular, 

that curve that is so troublesome here. I was a Board Member on scene at Spuyten 

Duyvil and that was a similar case of 80 miles an hour into a 30-mile-an-hour curve, 

and it had very predictable results. Physics does that. Usually in the design process, 

when you, as a designer or an engineer, realize that you've got a problem area, you 

try to figure out what the mitigation is. In this case, this curve was problematic. 

Who had the responsibility to point out or determine or take a first crack at the 

mitigations for an 80-mile-an-hour to a 30-mile-an-hour curve?

After a long pause, no one responded from the panel and Member Weener commented:

 47 An analogous function is performed in the marine industry by a “lookout.” A lookout is a crewmember at the 

ship’s bridge who maintains a continuous watch and reports any kind of navigational hazard - including other ships, 

debris, floating objects - to the officer on watch.
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That’s what I was afraid of. So, nobody’s responsible for the mitigation, the 

potential mitigation or at least the identification of that curve as being as 

problematic as it turned out to be?

Member Weener’s exchange during the hearing highlights the general sense that none of 

the participants understood the scope of their roles and responsibilities as they pertained to the safe

operations of the service. The NTSB concludes that had the WSDOT, Sound Transit, Amtrak, and 

the FRA been more engaged and assertive, and had clearly defined roles and responsibilities during 

the preparation of the inaugural service, it would have been more likely that safety hazards, such 

as the speed reduction for the curve, would have been better identified and addressed.

2.5.2 Railroad System Safety Analysis

Fatal derailments of two passenger trains led the FRA to develop and issue several 

emergency orders (EO) and safety advisories (SA) in 2013 and 2015.

48 They included:

• EO 29 - sent to Metro-North Railroad after the Spuyten Duyvil derailment to

identify all curve locations with speed reductions of 20 mph or greater and mitigate 

risks of overspeed derailments through signal modifications, PTC, crew focus 

areas, and/or enhanced signage.

• EO 31 - sent to Amtrak after the Philadelphia derailment to focus on the Northeast 

Corridor, identify all curve locations with speed reductions of 20 mph or greater 

and mitigate risks of overspeed derailments through signal modifications, PTC, 

crew focus areas, and/or enhanced signage.

• SA 2013-8 - sent to all passenger and intercity railroads to inform them of the 

circumstances of the Metro-North derailment and to focus compliance efforts on 

maximum authorized speed and permanent speed restriction locations.

• SA 2015-3 - sent to all passenger and intercity railroads to inform them of the 

circumstances of the Amtrak Philadelphia derailment and to survey their territories 

for all locations with permanent speed reductions of 20 mph or greater and to 

mitigate through signal modifications, PTC, crew focus zones, and or enhanced 

signage.

The two derailments occurred within 18 months of each other and involved passenger trains 

exceeding speed limits through curves.

The FAST Act also required the FRA to submit a report to Congress specifying FRA 

actions taken and summarizing completion status by all intercity passenger and commuter railroads 

to address safety concerns highlighted by FRA in EO 29, EO 31, SA 2013-8, and SA 2015-3. The 

 48 These two accidents were the December 1, 2013, accident at Spuyten Duyvil, Bronx, New York, involving 

Metro-North passenger train 8808, and the May 12, 2015, accident near Philadelphia, Pennsylvania, involving Amtrak 

passenger train 188.
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report was submitted in May 2016. Both Sound Transit and Amtrak provided responses to all these 

EOs and SAs.

The FAST Act required each railroad carrier providing intercity rail passenger 

transportation or commuter rail passenger transportation, in consultation with host railroad 

carriers, to survey their systems and identify each main track location where there is a reduction 

of more than 20 mph from the approach speed to a curve, bridge, or tunnel, and the maximum 

authorized operating speed for passenger trains at that curve, bridge, or tunnel, and develop 

appropriate actions to enable warning and enforcement of the maximum authorized speed for 

passenger trains at each of those locations. The plans must be reviewed and approved by the 

Secretary of Transportation, who is also provided authority to add conditions to the approval. The 

FAST Act did not require the FRA to continue to solicit updates from railroads beyond the initial 

submission deadline, nor did the FRA pursue additional submissions for new or updated routes 

from railroads that owned or operated service on such routes even though the FRA has authority 

to do so. Because the upgrade of the Lakewood Subdivision had not yet occurred at the time of the 

EOs or enactment of the FAST Act, the accident curve at MP 19.8 was not addressed in any speed 

limit action plans. Additionally, the FRA did not require railroads in the planning or construction 

phases of projects to evaluate the potential risk to future operational territories, and Sound Transit 

did not apply risk mitigation strategies as outlined by the FAST Act on the accident curve at MP

19.8.

The NTSB concludes that the FRA did not use its authority provided under the Fixing 

America’s Surface Transportation Act to approve speed limit action plans with conditions to 

require inclusion of planned and under-construction alignments owned or operated by railroads 

and require periodic updates to railroads’ speed limit action plans, which led to no speed limit 

action plan being developed.

Although the FRA participated in the Lakewood Subdivision project through Federal Grant 

Funding Administration and Safety Oversight, FRA officials located in both headquarters and in 

the field failed to recognize that additional hazard mitigations strategies were not implemented by 

Sound Transit or Amtrak on the Lakewood Subdivision at the accident location. The FAST Act 

did not require speed limit action plans to be submitted for new or upgraded territories by railroads 

that owned or operated service on such territories. The NTSB concludes that the FRA should have 

ensured that speed limit action plans include new or updated routes owned or operated by railroads, 

using its authority in the FAST Act. Therefore, the NTSB recommends that the FRA require 

railroads to periodically review and update their speed limit action plans to reflect any operational 

or territorial operating changes requiring additional safety mitigations and to continually monitor 

the effectiveness of their speed limit action plan mitigations. The NTSB also recommends that 

FRA require railroads to apply their existing speed limit action plan criteria for overspeed risk 

mitigation to all current and future projects in the planning, design, and construction phases, 

including projects where operations are provided under contract.

2.5.3 Sound Transit

On November 6, 2015, Sound Transit issued Sounder Commuter Rail Timetable #1. This 

timetable included the recommendation from FRA Safety Advisory 2015-03 by adding General 

Order 5, “Crew Focus Zones,” which required additional safety communication between the train 
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crew in advance of permanent speed restrictions.49 The only applicable location of the general 

order at that time was MP 3.4 northbound. At the time of publication of the timetable and general 

order, there was no passenger rail service south of Lakewood. Sound Transit submitted its FAST 

Act speed limit action plan to the FRA on June 28, 2016, and identified one location (MP 3.4)

which met the requirement.

50

In preparation for the initiation of passenger service on the entire Lakewood Subdivision, 

Sound Transit issued Sounder Commuter Rail Timetable #2, in effect at 0001 Pacific Continental 

Time, on November 13, 2017. The timetable contains various speed restrictions and specific 

instructions for freight, Talgo (Amtrak), and Sound Transit trains operating over the Lakewood 

Subdivision.

In the timetable, the permanent speed restriction at northbound MP 3.4 where the speed 

drops from 75 mph for Talgo trains at MP 4.1 to 35 mph at MP 3.4 (as previously identified in 

Sound Transit’s FAST Act Action Plan) continued to be acknowledged as a crew focus zone.

51

However, since their trains were not operating at the south end of the bypass at that time, Sound 

Transit did not designate MP 19.8 (where Talgo speeds drop from 79 mph to 30 mph) as a crew 

focus zone.

By not including MP 19.8 as a crew focus zone in their timetable, Sound Transit failed to 

apply the same level of speed restriction risk mitigation throughout the Lakewood Subdivisio n. 

When asked about adding MP 19.8 to the crew focus zone in the timetable, Sound Transit 

operations managers stated that “it would be incumbent upon Amtrak...on how they will comply 

with the FAST Act, not Sound Transit’s or BNSF’s responsibility because we don’t operate on the 

part of the territory.” NTSB investigators also found that Sound Transit did not coordinate with 

Amtrak in the development of the timetable even though Amtrak would be the sole tenant on the 

southern end of the operating territory. The operations manager’s response highlights a 

fundamental lack of understanding of a basic principle of railroading: the owner or host of the 

territory issues a timetable governing the operating speeds and special instructions that apply to 

tenant railroads. It further highlights both the lack of coordination between organizations and the 

lack of clear responsibilities between organizations during the safety certification phase of the 

Lakewood Subdivision upgrade project. The NTSB concludes that Sound Transit did not update

the timetable on its Lakewood Subdivision to identify the curve at MP 19.8 as a crew focus zone, 

which would have helped to mitigate the overspeed derailment risk. Therefore, the NTSB 

recommends that Sound Transit immediately conduct a review of all operating documents and 

ensure that safety mitigations are applied with uniformity throughout the entirety of its territory. 

In areas of its territory where Sound Transit is a host of a tenant railroad, the NTSB recommends 

 49 (a) The conductormust communicate with the engineer not less than 1 mile from an area where a reduction of 

speed of more than 20 mph takes affect and is required to take appropriate action to ensure the safe operation of the 

train if the engineer fails to acknowledge the restriction. (b) SA 2015-03 required additional safety mitigations at 

locations where there is a speed reduction of more than 20 mph from the approach speed to a curve, bridge, or tunnel 

and the maximum authorized operating speed for passenger trains.

50 SA 2015-03 was applicable to all passenger railroads and railroads that host passenger service.

51 Crew focus zones are locations where the operating crews are required to communicate warnings of upcoming 

speed restrictions.
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that Sound Transit coordinate with all current and any prospective tenants on the development of 

operating documents including timetables, general orders, and special instructions.

2.5.4 Amtrak

In response to FRA Emergency Order 31, May 23, 2015, Amtrak developed a speed limit 

action plan on July 2, 2016, that lists all locations meeting the mitigation requirements througho ut 

the Amtrak National Network where permanent speed restrictions are in place. On the day of the 

accident, the Lakewood Subdivision was not included in Amtrak’s speed limit action plan. In 

interviews with investigators, both Amtrak road foremen noticed that the permanent speed 

restriction at MP 19.8 should require a FAST Act speed limit reduction mitigation but did not 

elevate their concerns within the Amtrak management chain. The Amtrak assistant superintendent 

told investigators that the plan was to update Amtrak’s speed limit action plan in January (several 

weeks after revenue service had begun on the subdivision) through a general order that would be 

issued implementing a “crew focus zone” at MP 19.8. According to the assistant superintendent, 

this was the responsibility of the Amtrak Pacific Northwest Division and was overlooked prior to 

initiating service.52 The NTSB concludes that Amtrak failed to update the operating documents 

prior to starting revenue service which would have highlighted the speed reduction at the accident 

curve. The NTSB recommends that Amtrak update its safety review process to ensure that all 

operating documents are up to date and accurate before initiating new or revised revenue 

operations.

2.5.5 Safety and Security Management Plan

Sound Transit conducts safety verification and certification activities of new and 

refurbished systems including rolling stock and infrastructure in accordance with the 2015 Sound 

Transit Safety and Security Management Plan (SSMP). Sound Transit’s SSMP identifies the 

management structures, responsibilities, and authorities for documenting and confirming the tasks 

necessary to integrate safety and security into each phase of Sound Transit’s capital projects. The 

SSMP also required the evaluation, verification, and documentation of static and dynamic testing 

of installed systems, signage, and clearances through a safety certification process. 

Sound Transit used a contractor to build, test, and commission the newly refurbished track, 

infrastructure, and grade crossings on the Lakewood Subdivision. However, Sound Transit 

remained responsible for oversight of the contractor’s work, provided field staff during testing, 

and required contractor documentation to verify the testing and commissioning of installed 

equipment in accordance with relevant contract specifications. Sound Transit’s SSMP identifies 

plans, management structure, responsibilities, and authority for documentation, confirmatio n, 

activities, and tasks necessary to integrate safety and security into each phase of Sound Transit’s 

capital projects. The SSMP describes the integration of safety and security activities, includ ing 

methods for identifying, evaluating, mitigating, and resolving safety hazards and security 

vulnerabilities throughout all phases of the project, including preliminary engineering, final 

design, testing and start-up, and revenue service.

 52 The Amtrak Pacific Northwest Division is based in Seattle and responsible for train operations in the 

Northwestern United States. 
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During the earliest phases of the new Lakewood Subdivision project, Sound Transit 

developed a PHA which defined hazards present on the system using the methods outlined in

Sound Transit’s SSMP. In the PHA log dated April 21, 2015, Hazard No. SCR-PDB-123 identified 

the hazard of an overspeed derailment in all curves along the Point Defiance Bypass. In accordance 

with the SSMP, this hazard was determined to be unacceptable, thus requiring the following

mitigations:

• Ensure curves, elevation, and speed limitations are designed according to 

49 CFR 213.57(2), “Curves; elevation and speed limitations.”

• Develop inspection and maintenance procedures according to 49 CFR 213.233,

“Track inspection”

• Future implementation of PTC

Following this mitigation process, these mitigations lowered the frequency of the 

occurrence into an undesirable category that would require management to sign off on accepting 

the hazard. 

As the Lakewood Subdivision moved closer to completion, the PTC portion of the project 

had been delayed. The PHA document should have been modified because PTC had not been 

implemented. The PHA was never updated to reflect this change. With this omission in the PHA, 

Sound Transit turned the project over for revenue service with minimal controlling mitigations for 

speed restriction at the accident curve (as required by Hazard No. SCR-PDB-123). The final safety 

and security verification matrix included the same mitigations that were provided in the PHA;

however, the timetable had also been added as a controlling mitigation. As previously noted, Sound 

Transit’s SSMP references “procedures and training” as the lowest protective mitigation. On the 

day of the accident the status of the curve hazard was marked as “Completed Accepted.”

The Sound Transit Systems Integration Test Plan for the Point Defiance Bypass Project 

outlined a series of tests to be used to verify that all designed and constructed systems functio ned

in a safe and reliable manner. Completion of the Systems Integration Test Plan (SITP) was a 

prerequisite for issuing the safety certification of the project. Section 1.6 of the SITP included the 

following required tests:

• Design qualification tests

• Factory verification tests

• Construction inspection tests

• Field inspection and installation verification tests

• Acceptance tests

• Demonstration tests

• System integration tests
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• System familiarization exercises

• Prerevenue operations

A noticeable omission was the description of the last and final test, prerevenue operations. 

Neither an operational hazard analysis nor a prerevenue operations series of tests were performed 

on the Lakewood Subdivision during the transition from construction to revenue service.53 By not 

completing this type of review and testing, Sound Transit was unable to verify if the mitigatio ns 

developed in the PHA would actually work to control the hazard under actual operating conditions.

2.5.6 Safety Certification Process (Sound Transit Internal Oversight)

As defined by the Sound Transit SSMP, the Sound Transit System Safety Certificatio n 

Plan (SSCP) required the SQA to ensure that all facilities, systems equipment, safety procedures 

and plans, safety training programs, and emergency preparedness programs complied with safety 

requirements. These requirements included those mitigations developed through the hazard 

management process and were carried over to a certifiable items list (CIL). The CIL was used as 

a final verification tool to ensure that all elements have been tested and verified and served as the 

cornerstone of the safety certification process. Testing and verification were conducted by the SQA 

in coordination with the Operations Department and Design Engineering and Construction 

Management Department. Prior to initiating revenue service, the Chief Safety and Quality 

Assurance Officer certified compliance through a Safety Certification Verification Report 

comprised of multiple certificates of conformance that was delivered to the Sound Transit chief 

executive officer. The Safety Certification Verification Report and the CIL did not contain an 

operational hazard analysis, prerevenue operations testing, or a thorough review of the Final Safety 

and Security Verification Report. 

When a project moves toward completion with existing open items, an exception report 

will accompany the CIL and certificates of conformance. This report allows for a temporary 

mitigation while a longer-term solution to a hazard is implemented. Sound Transit should have 

exercised due diligence during the safety certification process by issuing a temporary mitigatio n 

to address the hazard of an overspeed derailment at the accident location. Ideally, Sound Transit 

could have waited until PTC was installed before operating the Cascades service on the bypass.

However, the hazard associated with the speed reduction was overlooked during the safety 

certification process and the mitigation was erroneously classified as “completed accepted.” The 

NTSB concludes that Sound Transit’s omission of the final activities of the certification process 

resulted in the failure to control the identified hazardous condition of an overspeed derailment at 

the accident curve. Therefore, the NTSB recommends that Sound Transit review its internal 

process for safety certification and verification, perform a gap analysis, and develop an action plan 

to address the deficiencies identified in the gap analysis and detailed in this report to enhance the 

verification activities on projects. 

As a result of Sound Transit omitting the final activities of the certification process, the 

NTSB concludes that Sound Transit failed to implement effective mitigations in lieu of PTC to 

control the hazard at the accident curve. Further, the NTSB concludes that there was no 

 53 Sound Transit did complete testing on all grade crossing warning devices. 
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requirement for WSDOT, Sound Transit, or Amtrak to provide additional protection for the 

accident curve.

The NTSB’s May 12, 2015, accident report regarding the derailment of Amtrak train 188 

near Philadelphia, Pennsylvania, discussed possible technologies that could, when PTC was not 

available, effectively mitigate hazards associated with engineers becoming spatially disoriented

(NTSB 2016). In the Philadelphia accident, the engineer overlooked the speed restriction of an 

upcoming curve and derailed the train. There are similarities between the DuPont and Philadelp hia 

accidents regarding engineers failing to recognize an upcoming curve and associated speed 

restrictions. In both accidents there was no active PTC in place and the physical cues for the 

engineers were not significant enough to alert them of the upcoming speed restriction. In the 

Philadelphia report, the NTSB stated, “the engineer likely would have benefitted from technology 

that showed him the location of his train in real time, which would have also helped him establish 

and maintain his situational awareness.” As a result, the NTSB issued the following Safety 

Recommendation to the FRA:

Require railroads to install devices and develop procedures that will help 

crewmembers identify their current location and display their upcoming route in 

territories where positive train control will not be implemented. (R-16-32)

The FRA’s initial response (February 9, 2018) suggested that this recommendatio n 

required the development and testing of new technologies before it could evaluate its 

implementation. In order to move forward on the recommendation, the FRA planned to determine 

the following:

• The level of interest within the community

• If the technology would improve safety

• The cost (inclusive of other resources) necessary for deployment

• The potential benefits relative to the societal costs

On March 28, 2019, the FRA wrote that it discussed the recommendation with the Class I 

railroads who believed that the technology needed to satisfy the recommendation was not 

available, and that they did not intend to develop it. The FRA also asserted that 49 CFR Parts 240 

and 242 already require locomotive engineers and conductors to be familiar with the physical 

characteristics of the territories in which they work. Under these regulations, the FRA initiated 

multiregional audits of the railroads, focusing on operations in nonsignaled territory.

The FRA concluded its March 28, 2019, letter saying that the need for Safety 

Recommendation R-16-32 was “dubious” and the costs would “certainly be tremendous, costing 

at least in the hundreds of millions of dollars . . ..” Given that the technology does not exist, that it 

had “little to no known safety benefits” to offset its significant cost, and that a regulation requiring 

railroads to install the technology would be redundant with existing rules, the FRA did not plan to 

take the recommended action.
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In issuing Safety Recommendation R-16-32, the NTSB believed that the recommended 

technology was readily available and affordable. Moving map displays that use global positioning 

systems (GPS) are commonly available in personal cell phones and tablets used by many people. 

As a result, the NTSB is concerned that both the FRA and the Class I railroads that reviewed the 

recommendation did not fully understand it.

Amtrak briefed NTSB investigators on May 20, 2019, on their recent development of a 

moving map display designed to enhance situational awareness of the train crews on their route. 

The application, called AWARE, monitors the position and speed of a train in real-time. Amtrak 

demonstrated a proof of concept in November 2018 and is working on a targeted deployment of 

the application on territory with a Positive Train Control Mainline Track Exclusion Addendum 

(MTEA) in 2019 with system-wide deployment to follow.

The NTSB believes that this recommendation is applicable to the DuPont accident. In both 

the Philadelphia accident and the DuPont accident, experienced engineers who were in compliance 

with 49 CFR Part 240 became disoriented. In the Philadelphia accident, a qualified and 

experienced engineer became spatially disoriented when his attention was diverted. The engineer 

in the DuPont accident knew of the speed restriction, but because he was not familiar with the 

territory and the approaching speed restriction, he failed to slow the train. Other human factors 

considerations, such as poor visibility or unexpectedly high workload, can also contribute to an 

engineer becoming spatially disoriented. The NTSB now understands that using readily available, 

low-cost technology, such as GPS and moving map displays, is a potential technology solution 

that the FRA did not consider. The NTSB believes that, in both the Philadelphia and DuPont 

accidents, this technology would have likely helped both engineers remain spatially oriented. 

Although the FRA and Class I railroads believe that the required technology is not available and 

would be expensive to develop, and that 49 CFR Parts 240 and 242 fully address the safety issue, 

despite our findings, the NTSB asks that the FRA reconsider this decision in view of the 

availability and cost of the actual recommended technology. The NTSB concludes that because 

the FRA did not act on the recommendation to add technology to assist engineers in determining 

their location, an opportunity to improve safety was overlooked. Consequently, Safety 

Recommendation R-16-32 is reiterated and is classified “Open—Unacceptable Response.”

2.5.7 External Oversight of Sound Transit 

Because federal and state funding was used in the development of the Point Defiance 

Bypass project, the FRA and WSDOT were responsible for providing oversight of Sound Transit, 

who was the subgrantee to the project. Although most of these oversight elements were financial 

in nature, both agencies were responsible for ensuring that the project would be safe to operate,

and that Sound Transit’s safety certification process was followed. In its contract with Sound 

Transit for the construction and completion of the project, WSDOT required Sound Transit to 

complete a Safety Security Certification Verification Report to certify that the project was “safe 

and ready for use in revenue operations.” Although WSDOT staff ensured that the project was 

proceeding according to schedule and budget, their role in overseeing safety was limited. One 

WSDOT staff member participated in both Sound Transit’s PHA activities and some testing,

including grade crossing testing and validation. However, WSDOT did not have a formalized 

approach to oversee the implementation of Sound Transit’s safety certification process, nor was 
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there a requirement for WSDOT to do so. The NTSB concludes that WSDOTshould have provided 

greater oversight of Sound Transit’s safety certification process.

To meet federal rail project funding requirements, the FRA required grantees to submit 

design plans, proposed expenditures, construction bids, and other documents required by the 

HSIPR Program under the ARRA. In this case, the FRA provided written approvals to WSDOT 

that included approvals for preliminary engineering, final design implementation, and constructio n 

stages for the bypass. Under the funding requirements, the FRA also required that WSDOT submit 

a System Safety Program Plan. However, the FRA is only required to review such plans, not to 

approve them. In this case, because the project was being constructed by Sound Transit, Sound 

Transit’s Safety and Security Management Plan would apply. The NTSB concludes that the FRA’s 

current requirement to review, but not approve, SSPPs does not achieve the level of safety 

oversight expected from the FRA. 

The FRA’s role in oversight of railroad funding projects is split between grant oversight 

and safety oversight. The policies and procedures in the grantee’s or subgrantee’s SSMP involving 

safety processes to be followed during project design, construction, and prerevenue testing are 

grant requirements, and the FRA Passenger Rail Division provides guidance and feedback on these 

safety documents. But the FRA has no regulatory authority to approve or require changes to an 

SSMP or the SSMP’s implementation. The FRA Office of Safety (which includes the Passenger 

Rail Division) will in some instances perform site visits and observe prerevenue activities. In the 

case of the Point Defiance Bypass, the Passenger Rail Division reviewed Sound Transit’s hazard 

management program but only as a deliverable of the grant. Although there were also 34 field and 

compliance inspections conducted by the FRA regional office prior to the initiation of revenue 

service (these included track, signal, operating practices, grade crossings, and motive power and 

equipment), none of these inspections noted the deficiencies that were evident during the safety 

certification phase of the project. Since the FRA’s role in SSMP oversight is limited, the FRA was 

unable to ensure that mitigations to protect the accident curve in lieu of PTC were implemented.

As shown in this accident, NTSB concludes that without PTC and the lack of oversight to 

implement mitigations, there was an increased safety risk to the traveling public. Therefore, the 

NTSB recommends that the FRA prohibit the operation of passenger trains on new, refurbished, 

or updated territories unless positive train control is implemented.

As the eventual operator of passenger rail service over the upgraded Point Defiance route,

Amtrak participated in prerevenue meetings over several years that detailed the planned route, 

operating environment, and inherent safety hazards. Sound Transit invited Amtrak to participate 

in several activities related to the safety certification of the Point Defiance Bypass project,

including the PHA and various tests and validations (some tests are federally mandated such as 49 

CFR 238.111(a) which is testing to validate equipment and track and signal compatibility).

However, these tests did not include the appropriate safety department at Amtrak. Amtrak's 

involvement in these prerevenue planning, engineering, and construction activities provided 

opportunities to become aware of the safety hazards and their planned mitigations, such as the use 

of PTC for safety protection at the 30-mph curve and the intent to use the Talgo trainsets. However, 

as the preparation activities progressed toward completion, Amtrak failed to make Sound Transit 

aware of their incomplete and inadequate safety controls. As the railroad of record, Amtrak had a 

duty to eliminate the risk to the lowest practicable level. For example, Amtrak accepted the use of 

timetable protection for the 30-mph curve, instead of the recommended PTC protection identified 
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in early risk analyses for the route. Moreover, Amtrak, as the railroad of record, submitted the 

petition to the FRA to exempt Talgo railcars, not only for the Point Defiance route but two other 

west coast routes, despite awareness that the railcars did not meet prevailing safety standards for 

crashworthiness. When asked about Amtrak’s verification that the grade crossing warning devices 

on the Point Defiance Bypass were tested, verified, and working properly, the Amtrak general 

superintendent stated to investigators, “Our assumption is grade crossings work properly when the 

host railroad says the railroad is ready for you to operate on it.” The NTSB concludes that Amtrak 

did not take an active enough role in reviewing safety aspects during the preparation of the Point 

Defiance Bypass to ensure a safe operation. The NTSB also concludes that Amtrak failed to assess, 

evaluate, and act upon readily identifiable safety hazards to ensure the safety of the Point Defiance 

Bypass for the traveling public and its own train crews. Therefore, the NTSB recommends that 

Amtrak incorporate all prerevenue service planning, construction, and route verification work into 

the scope of it's corporate-wide system safety plan, including its rules and policies, risk assessment 

analyses, safety assurances, and safety promotions.

Unfortunately, this accident is just one of several that have occurred recently where Amtrak 

has been unable to control or influence the management of safety on the host railroad.

On October 5, 2015, at 10:22 a.m. eastern daylight time, southbound Amtrak train 55, 

derailed at MP 65.2 on a single main track after striking a rock pile that fouled the right of way on 

the New England Central Railroad (NECR) near Northfield, Vermont (NTSB 2017a). The 

collision and subsequent derailment resulted in the locomotive and first coach railcar derailing and 

sliding down an embankment. Three additional coach railcars derailed but remained upright and 

in-line near the track. This accident highlighted that although Amtrak used a hazard management 

program on its owned and operated territory through its System Safety Program Plan (SSPP), this 

program was not applicable on a host railroad. The Amtrak SSPP hazard management program 

established a methodology for determining risk and the mitigation of this risk; the risks addressed

by Amtrak included rock fall and rock slide areas along the Northeast Corridor and Harrisburg 

Line. In contrast, although the NECR had a safety program, at the time of the accident the NECR 

did not have a formalized hazard management and assessment program as it pertains to rock fall 

risk management and mitigation.

On March 14, 2016, at 12:02 a.m. central daylight time, Amtrak train 4 derailed near 

MP 372.9 in the vicinity of Cimarron, Kansas (NTSB 2017b). This Los Angeles to Chicago train 

consisted of two locomotives and ten railcars. Four railcars were derailed on their sides, one railcar

derailed and was leaning, two railcars derailed upright, and one railcar derailed a single truck. The 

accident occurred on the BNSF Railway. A runaway feed truck from an adjacent feedlot impacted 

the railroad tracks and pushed the tracks out of alignment. At the location of the accident, there 

were no protective barriers or fencing placed along the right of way to prevent this undesirable 

intrusion. Along the Amtrak-owned and -operated Northeast Corridor and Harrisburg line, Amtrak 

implemented an intrusion prevention strategy to develop standards and install fencing and barriers 

to reduce the risk of vehicle intrusion onto the right of way.54 Amtrak does not require the same 

risk reduction strategies from its hosts. 

 54 Amtrak Intrusion Prevention on the NEC Presentation, November 16, 2015.
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On February 4, 2018, about 2:27 a.m. eastern standard time, southbound Amtrak train 91, 

operating on a track warrant, diverted from the main track through a hand-thrown switch into a 

siding and collided head-on with stationary CSX Transportation (CSX) local freight train F777 03. 

The accident occurred on the CSX Columbia Subdivision in Cayce, South Carolina (NTSB 2018b). 

The engineer and conductor of the Amtrak train died as a result of the collision. At least 92 

passengers and crewmembers on the Amtrak train were transported to medical facilities. Although 

this accident is still under investigation, preliminary information from the investigation suggests 

that the Amtrak train was authorized to operate through the territory at maximum authorized speed 

during a signal outage.

55 This differs from the current operating plan that Amtrak uses during 

planned signal outages and unplanned signal outages on their own property. 

During the NTSB investigative hearing on this accident, Amtrak officials discussed the use 

of host railroads to operate the majority of route miles of Amtrak services across the United States. 

Amtrak uses a Host Railroad Agreement to gain access to the host’s right of way and to define the 

fee structure paid for such access. As discussed during the hearing, the Amtrak Host Railroads 

Team said that the team infrequently discussed safety issues and that it was unclear the extent to 

which safety provisions were contained in the host railroad agreements.

These accidents highlight that there is inconsistency in the approach to managing safety on 

Amtrak-owned and -operated territory versus that of a host’s territory. Amtrak relies on host 

railroads to meet the minimum federal safety standards to ensure safe operations of Amtrak trains. 

However, on its own territory, Amtrak aims to meet and exceed these standards by not only 

meeting the minimum safety standards required by federal regulation, but also historically using a 

System Safety Program Plan, not required federal regulations, and more recently after a 

recommendation from the NTSB, implement a safety management system (SMS). The effort to 

develop and implement an SMS at Amtrak will enhance the management of safety across the 

system but it may be more challenging to implement on a host railroad. These enhancements will 

go beyond the current minimum standards used by the host railroads. The NTSB concludes that to 

improve safety for the public, Amtrak needs to implement an SMS on all of its operations whether 

internal, host railroad, or in states that own infrastructure over which Amtrak operates. Therefore, 

the NTSB recommends that Amtrak work collaboratively with all host railroads and states that 

own infrastructure over which you operate in an effort to develop a comprehensive safety 

management system program that meets or exceeds the pending FRA regulation 49 CFR Part 270, 

“System Safety Program.”

On April 3, 2016, about 7:50 a.m. eastern daylight time, southbound Amtrak train 89 struck 

and killed a worker inside a backhoe at MP 15.7 near Chester, Pennsylvania (NTSB 2017). As a 

result of this investigation, the NTSB identified the need for Amtrak to implement a formal System 

Safety Program, and issued recommendations to Amtrak to take this action. One of the challenges 

faced by all railroads in developing a formal System Safety Program, has been the failure of the 

FRA to enact its final rule. Many of the railroads have designed their System Safety Program but 

are apprehensive about implementing their plan because of concerns that modifications will be 

necessary after the System Safety Program regulation is fully enacted. At the time of the NTSB’s 

 55 A train operating through a signal outage does not rely on wayside or cab signaling receive movement authority 

through the territory, in this case movement authority was authorized by the CSX dispatcher. 
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report on the accident in Chester, the FRA had delayed the rule’s implementation four times. As a 

result, the NTSB issued Safety Recommendation R-17-17 to the FRA:

Enact Title 49 Code of Federal Regulations Part 270, “System Safety Program,” 

without further delay. (R-17-17)

In the 2 1/2 years since the final rule was published, the FRA has granted six extensio ns 

that have delayed this rule until its currently scheduled effective date of September 4, 2019. In 

the years since the rule was published, accidents have continued to occur. In addition to the 

accident near Chester, Pennsylvania, and the accident in DuPont, Washington, the NTSB is also 

investigating the February 4, 2018, accident involving Amtrak train 91, which diverted from the 

main track through a hand-thrown switch into a siding and collided head-on with a stationary 

CSX Transportation freight train in Cayce, South Carolina (NTSB 2018b). The engineer and 

conductor of that Amtrak train died, and 92 passengers and crewmembers were transported to 

medical facilities. On April 22, 2019, pending implementation of the final rule, Safety 

Recommendation R-17-17 was classified “Open—Unacceptable Response.” The Chester 

accident occurred on Amtrak’s own property. As shown by this accident and others, Amtrak 

operates on host railroads throughout the United States. The system safety regulation would not 

be limited to Amtrak property and would be applicable to all of Amtrak’s operations includ ing 

those on host railroads. With the regulation in place, the relationship between the host railroad and 

Amtrak would be better defined and Amtrak could present to the host railroads their regulatory 

obligations. The NTSB concludes that the repeated postponement of 49 CFR Part 270, “System 

Safety Program,” has delayed needed safety improvements for the passenger rail industry, rail 

employees, and the traveling public. Therefore, the NTSB reiterates Safety Recommendatio n 

R-17-17.

NTSB investigators learned that following this accident, Amtrak officials developed a risk 

assessment process to be used to evaluate the risks to Amtrak operations over a new or upgraded 

service. The process includes using expertise from Amtrak’s System Safety Office and local 

transportation management officials. Since its development, this risk assessment process has been 

used several times by Amtrak including on the return of service to the Point Defiance Bypass. 

Amtrak operations and safety officials stated to investigators during interviews that Amtrak will

mature its risk assessment process and use it on all new or upgraded future services. The NTSB 

concludes that the use of risk assessments to identify, mitigate, and control risk on new and 

upgraded service will increase the level of safety to Amtrak operations over all territories. 

Therefore, the NTSB recommends that Amtrak conduct risk assessments on all new or upgraded 

services that occur on Amtrak-owned territory, host railroads, or in states that own infrastructure 

over which you operate.

2.6 Equipment Crashworthiness

When the leading locomotive and the Talgo Series VI trainset derailed, they were 

immediately subjected to a severe longitudinal load and a bending moment as a result of the sudden 

deceleration in the sharp curve.56 The sudden deceleration was a direct result of the train’s 

interaction with the surrounding environment, such as soil and ballast foundation of the track 

 56 This was an 8° 22-minute curve.
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structure, bridge structures, the jackknifed trainset railcars, and trees. The forces associated with 

the derailment and the bending moment caused the leading locomotive to separate from the first 

railcar in the trainset and several of the articulated connections of the trainset to fracture, triggering 

the separation of passenger railcars. In this derailment, a total of six articulated connections failed. 

The locomotive and derailing railcars were then exposed to secondary collisions after they derailed 

from the tracks. The outcome from many of those secondary collisions resulted in the catastrophic 

failure of passenger railcar body structures because of the complex and uncontrolled movement of 

passenger cars, which led to the loss of survivable space, side passenger window failures, several 

passenger ejections, injuries, and three fatalities.

AMTK 7424 (8) and AMTK 7504 (7) were those passenger railcars in the trainset that 

suffered the most severe compromise of their railcar-body structures. AMTK 7424 (8) traveled off 

the overpass to the southeast (compass direction) with its leading end directed toward the adjacent 

bridge embankment. The railcar then nosed downward, upended, and overturned end-over-end, 

resting on its roof where it then struck a truck trailer traveling on I-5. Overall, the secondary 

collisions and interactions with the surrounding environment resulted in about 30 percent of the 

right sidewall shearing from the side sill and roof line. The roof was split and opened from the 

suspended end to about the center of the railcar. Four of five right-side passenger windows were 

missing as a result of the secondary collisions. The end wall structure of the suspended end of 

AMTK 7424 (8) was completely separated from the end frame structure as a result of its interactio n 

with the truck and trailer collision and other secondary collisions as it fell from the embankment. 

The left-side wall of AMTK 7424 (8) was heavily scraped and abraded but remained intact. The 

structure was slightly pushed inward from the suspended end to the approximate center of the 

railcar. The roof line from the suspended end to the approximate center of the railcar-end was 

fractured and slightly pushed inward. Four of five left-side windows were missing, likely due to 

the collision. In total, there were 11 passengers traveling in this railcar; of these, 5 were ejected, 

and a total of 10 were injured, and 4 of the injuries were deemed severe. The NTSB concludes the 

Talgo Series VI passenger railcar AMTK 7424 (8) did not provide adequate occupant protection 

after its articulated connections separated, resulting in complex, uncontrolled movements and 

secondary collisions with the surrounding environment which led to damage so severe to the railcar

body structure, that it caused passenger ejections.

The unique design of the Talgo Series VI trainset rolling assembly and its vulnerability to 

detachment further contributed to the severity of secondary collisions. The observations in this 

derailment demonstrated that the rolling assembly is prone to separation when the trainset’s 

articulated connection fails. In this derailment, five rolling assemblies fully detached, and one 

partially detached. One fully detached rolling assembly was involved in a secondary collision with 

a separated Talgo Series VI passenger railcar resulting in the three fatalities. Passenger railcar

AMTK 7504 (7) struck the rolling assembly from AMTK 7422 (10) during the secondary 

collisions after the derailment whereupon the railcar structure of AMTK 7504 (7) was severely 

compromised. The Talgo Series VI trainset rolling assemblies are susceptible to detachment when

the articulated connections fail in a high-energy derailment or collision. Based on the examinatio n 

of the postaccident damage, photographic documentation collected by the Federal Bureau of 

Investigation Evidence Response Team and the location of the human remains prior to the 

northeast bridge abutment that passed over the lanes of southbound I-5, AMTK 7504 (7) collided 

with the detached rolling assembly from AMTK 7422 (10) after the articulated connections failed 

on both railcars, thereby resulting in the rolling assembly physically penetrating AMTK 7504 (7).
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The three fatalities that occurred in AMTK 7504 (7) were all the result of blunt force trauma. Two 

of the fatally injured passengers were ejected from the compromised railcar-body structure of 

AMTK 7504 (7) when the side wall of the railcar was breached by the rolling assembly from 

AMTK 7422 (10). The rolling assembly tore a hole into the underside of the railcar as it flipped 

over onto its right side during the derailment. The rolling assembly was found partially inside of 

the railcar. In addition, two more passengers were partially ejected out of the opening created by 

the railcar’s structural breach. Another passenger was fatally injured when he was struck by the 

rolling assembly inside of the railcar. The NTSB concludes that the failure of the articulated 

connections of both Talgo Series VI passenger railcars AMTK 7422 (10) and AMTK 7504 (7), the 

detached rolling assembly from AMTK 7422 (10) and its secondary collision with AMTK 7504 

(7) directly resulted in three fatalities and two partially ejected passengers who had been traveling 

in AMTK 7504 (7).

The rolling assembly of AMTK 7424 (8) detached during the derailment and traveled 

across the southbound lanes of I-5. A green Kia Soul and a black Jeep Grand Cherokee were struck 

by the rolling assembly which weighed about 4,500 pounds. The rolling assembly struck the front 

hood of the Kia and the rear of the Jeep, causing both drivers to lose control of their vehicles. Both 

vehicles sustained extensive crush damage resulting from the impact with the rolling assembly. 

The driver of the Kia was injured and pinned inside of the vehicle when the engine block was 

shoved rearward, collapsing the dashboard and steering column onto the driver. The driver had to 

be extricated by first responders. After being struck by the rolling assembly, the Jeep then rotated 

180°, striking the metal guardrail before coming to final rest. The Jeep occupant also received 

minor injuries in the accident.

The grandfathering provision approved by the FRA (discussed in further detail in 

section 2.6.2 of this report) allowed the use of the Talgo Series VI trainset subject to the condition 

(one of several conditions that were required to be met) that the railcars must be modified by 

applying safety cables between the railcars and bogies (truck assemblies) to resist a minimum total 

longitudinal force of 77,162 pounds to prevent separation of the railcar-bodies and rolling 

assemblies. The NTSB learned the limit of the force was constrained because any greater force 

would compromise the end-wall structure of the railcars. This addition was required because the 

original design of the rolling assembly was primarily held in place by guidance arms and the FRA 

was concerned the rolling assembly could detach during an accident. Examination of the 

postaccident performance of the modification showed there was a high percentage of failure of the 

cables. The cables installed were, in fact, not cables; they were lightweight high-strength polyester 

straps. When the term “cable” is used in manufacturing and design industry, it is associated with 

a steel braided material, not a polyester material. Although similar strength is achievable with 

nylon materials, nylon has a life expectancy associated with it. Nylon and polyester straps possess 

a limited useful outdoor service life due to degradation caused by abrasion, exposure to natural 

elements, temperature gradients, and exposure to sunlight or other measurable sources of 

ultraviolet radiation. An industry best practice, at a minimum, would require that polyester straps 

regularly exposed to outdoor conditions be identified with the date they are placed into service and 

be periodically proof tested to their rated capacity. The investigation determined, through 

communication with Talgo, that there was no maintenance or design specification that established 
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either periodic proof testing or a prescribed service life of the strap.57 In other words, there were 

no measurable inspection requirements beyond a periodic visual assessment and no established 

service life to specify how long the strap would be expected to meet the design expectations before 

environmental degradations would occur and the strap was no longer capable of meeting the 

strength requirements. The NTSB tensile tested several samples of straps collected from the 

accident trainset and exemplar straps from another Talgo Series VI trainset currently in service. 

The results determined that the individual straps that were tested fractured at tension loads that 

were about 10 to 50 percent of the rated tension breaking strength. The NTSB concludes that the 

safety straps used for the Talgo Series VI trainset rolling assembly retention modifications were 

degraded due to their use in exposed outdoor conditions and were used far past their service life. 

In its examination of the proposed modifications during the grandfathering approval process, the 

FRA neglected to consider that the high strength polyester fabric strap would degrade and become 

weaker over time. Had the FRA considered that this type of manufactured material degrades over 

time, they could have either established maintenance requirements to both periodically test and 

change the straps at intervals or required the use of a steel braided cable with an effective life of 

20 years. The NTSB concludes that during the grandfathering approval process, the FRA failed to 

consider the limited useful service life of the polyester straps used for the Talgo Series VI trainset 

rolling assembly retention modifications which had degraded and failed to improve the 

crashworthiness of the train.

2.6.1 Historical and Regulatory Approach to Crashworthiness

The NTSB has investigated several accidents in its history where the issue of 

crashworthiness performance of rail passenger vehicles involved in secondary collisio ns 

contributed to the overall severity of the accident. On January 26, 2005, the NTSB launched a team 

to Glendale, California, to investigate a collision between a Metrolink commuter train and a 

highway passenger vehicle.58 The northbound Metrolink train struck an unoccupied sport-utility 

vehicle on the track. The train derailed and impacted a standing freight train and jackknifed into a 

northbound train. There were 11 fatalities and more than 100 injuries as a result of this accident. 

Although the NTSB closed this investigation due to a criminal investigation associated with the 

driver of the sport-utility vehicle, the derailment prompted the FRA and Volpe to examine the 

crashworthiness of the rail vehicles involved in this accident. In its report, Volpe stated that despite 

the complex motions of passenger [railcars] involved [in this accident], the principle causal 

mechanism for the fatalities and serious injuries in the Glendale accident was the loss of survival 

space due to the gross deformation of the railcar structure. In other words, the secondary collisio ns 

with nearby trains after the initial impact with the sport-utility vehicle were the impetus of the 

railcar-body failures.59

As mentioned in section 1.11.5 of this report, as a safety requirement, all passenger railcars 

that operate in the United States must have corner and collision posts. The derailment and 

 57 Talgo explained to NTSB investigators they performed an exterior calendar day mechanical inspection of 

passenger equipment required by 49 CFR 238.303 “Exterior calendar day mechanical inspection of passenger 

equipment,” prior to the accident, but now specifically includes inspection of safety straps.

58 Closeout memorandum, NTSB Docket DCA05MR009.

59 Proceedings of the ASME/ASCE/IEEE 2011 Joint Rail Conference, JRC2011, March 16-18, 2011, Pueblo, 

Colorado, USA; Crashworthiness Analysis of the January 26, 2005, Glendale, California, Rail Collision.
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subsequent collision of two Metro-North trains on May 17, 2013, demonstrate the need and benefit 

to passengers traveling in passenger trains with these features. The eastbound Metro-North 

passenger train derailed from main track 4 of the New Haven line subdivision near Bridgeport, 

Connecticut, and was struck by a westbound Metro-North passenger train that was traveling on an 

adjacent track. As a result of the collision, 62 passengers, 2 engineers, and 1 conductor were injured

(NTSB 2014). After the eastbound train derailed, it was struck and sideswiped by the westbound 

train. In an examination of the crashworthiness performance of the railcars involved, the NTSB 

found that a structural corner post of one of the severely deformed railcars did provide a 

measurable level protection, but in its investigation, the NTSB determined that the corner post did 

not meet federal structural requirements. This example is relevant for two reasons, (1) the Talgo 

Series VI passenger cars do not have corner or collision posts and (2) like in many derailments, 

trains often enter the adjacent track and can be subjected to secondary collisions from another 

train.

The approach to crashworthiness in the United States historically has focused on the static 

end strength of the individual train railcars and locomotives. In May 1999, the FRA published a 

final rule requiring improved crashworthiness standards that included structural enhancements to 

the railcar body such as collision posts, corner posts, anticlimbing mechanisms, mechanical 

coupler strength requirements, and truck to railcar-body attachment requirements. The basis of this 

approach was to protect occupants from the loss of survivable space during a collision by 

strengthening the railcar structure and prevent railcar-to-railcar overrides when a collision occurs. 

In the 1999 final rule the FRA stated that it was concerned with the level of safety by passenger 

equipment designed to European and other international standards when such equipment is 

operated in the United States. The FRA stated (at the time of publication) that overall trainsets in 

Europe did not meet the structural standards common in the United States, and the FRA believed 

that the adherence to such standards by the United States had contributed to a high level of safety. 

Codifying these standards was the FRA’s approach to assure that a high level of safety was 

guaranteed when operating passenger trains in the comingled environment with heavy freight 

trains and numerous grade crossings, specifically if the European trainset becomes desired for use 

in the United States. Recently the FRA published a final rule (effective January 22, 2019) that 

amends passenger equipment safety standards allowing the use of a performance-based approach 

to crashworthiness design. Specific to Tier I trains (trains that operate at a maximum speed of 

125 mph) the final rule establishes an alternative approach to meeting crashworthiness so that 

features like crash energy management can be used on a performance basis rather than the 

prescriptive requirements currently in use (Federal Register 2018, 25020).

The concept of the trainset is not unique in Europe and internationally.60 From a 

crashworthiness perspective, and as is the case with the Talgo Series VI operating in the United

States, the operating approach of the trainset places unoccupied railcars (equipment railcar and 

baggage railcar) at each end of the trainset. Then a locomotive or cab railcar is used to operate the 

train. The individual railcars in the trainset are constructed to resist a longitudinal static load of 

about 450,000 pounds, which is significantly less than the United States requirement of 

 60 A semipermanent trainset is one in which cars are coupled through an articulated connection. This connection 

cannot be traditionally uncoupled like traditional North American mechanical couplers. The trainset is retained in its 

configuration unless special tools are used by qualified mechanics in a facility.
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800,000 pounds. In addition, except for the equipment railcar, there are no corner or collision posts 

as part of the structural design of the individual passenger railcars, unlike the United States 

requirements which require all passenger railcars that operate in North America to have full height 

corner and collision posts.61 The only excepted railcars are those which had been grandfathered to 

operate in the United States by the FRA. It should be noted that the Talgo Series VI is the only 

passenger railcar that received grandfathered approval by the FRA that operates in the United 

States. According to the analyses presented to the FRA from Amtrak and Volpe, it had been 

theorized that the presence of unoccupied railcars would provide a level of protection at each end 

of the trainset in a train-to-train collision. The theory is that the initial energy from the collisio n 

forces would be absorbed by the unoccupied railcars thus protecting the occupants traveling in the 

center section of the trainset. This approach fails to consider two key risks: (1) the analysis 

presented to the FRA for grandfathered approval considered only train-to-train collisions with 

similar types of trains, not freight trains which can weigh more than 10,000 tons versus the weight 

of the accident train at 461 tons, and (2) the risks associated with secondary collisions from the 

surrounding environment that often is associated with the train departing the track and collid ing 

with adjacent trains (raking collisions) and trainset buckling (jackknifing) and/or individual railcar

separation due to railcar-to-railcar connection failures.

In the DuPont, Washington, derailment, several articulated connections failed in a way that 

was predicted by the FRA and Volpe as discussed in the FRA’s final approval to grandfather the 

Talgo Series VI trainset. Several individual railcars in the trainset separated whereby the 

passenger-occupied railcar structures with their deficient end-strength design and no corner or 

collision posts were fully exposed to all surrounding environmental risks. Had this accident 

occurred on double track territory and another passenger railcar or fully loaded freight railcar

collided with these railcars such as in the 2005 Glendale, California, accident, the accident 

outcome would have resulted in significantly more loss of survivable space. In the 2013 

Bridgeport, Connecticut, accident, the NTSB observed that the corner posts provided measurable 

protections against the loss of occupied space (NTSB 2014). If this type of accident had occurred

with a Talgo trainset in which the individual passenger cars did not have corner posts, the outcome 

would have resulted in a significant loss of survivable space. The Vancouver, British Columbia,

derailment occurred with the train traveling at only 3 mph when it derailed into an adjacent freight 

car tearing into the side structure of Talgo Series VI passenger cars. Had this accident occurred at 

speeds like the Dupont, Washington, derailment, the outcome would have resulted in a significant 

loss of survivable space.

The demonstrated behavior of the Talgo Series VI trainset derailments and the behaviors 

of railcars in many other derailments and collisions investigated by the NTSB provide a substantial 

and conclusive basis to predict postevent outcomes of railcars during an accident. In a severe or 

high-energy accident, the railcars often depart from the tracks and into adjacent surroundings. The 

physics of the sudden deceleration of the train during a derailment or collision and the following

forces from the trailing railcars are the dominant contributor to this behavior, which typically 

results in jack-knifed individual railcars. The railcars are then exposed to the surrounding 

environment which can include, nearby trains, automobiles, and rigid wayside structures. The 

crashworthiness of the individual railcars must be able to resist, to some degree, the crush that they 

 61 A recent Notice of Proposed Rulemaking proposed new recommendations for the Tier I passenger equipment 

and allows for alternate compliance in 49 CFR Part 238. 
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will be exposed to from secondary collisions. Since 1999 in the United States, crashworthiness 

requirements that include the end-strength of 800,000 pounds, corner and collision posts, and other 

structural minimums have been mandatory. The benefit of having these required structural features 

on all railcars has improved safety for passengers, specifically when there has been an accident 

and the railcars depart the tracks into adjacent track or other environmental features that can lead 

to catastrophic failure. Based on the failed articulated connections, the lack of 

United States-compliant structural protections of the Talgo Series VI railcar-body, and the 

demonstrated behavior of the trainset in a derailment, the NTSB concludes that the Talgo Series 

VI trainset is structurally vulnerable if it is involved in a high-energy derailment or collision due 

to its lack of crashworthiness protections and is at risk to severe and catastrophic loss of survivab le 

space.

2.6.2 Grandfathering

Title 49 CFR 238.203(d), “Grandfathering of Non-Compliant Equipment for Use on a 

Specified Rail Line or Lines,” provides a provision for a railroad to petition the FRA to permit the 

use of rail equipment not meeting the then-newly published requirements for static end strength. 

The petitions submitted were required to include (summarized): 

• Detailed drawings and material specifications, engineering analysis sufficient to 

describe the performance of the static end strength and its performance in a collision 

• Risk mitigation efforts employed in connection with the use of the equipment

• A quantitative risk assessment demonstrating the use of the equipment in the service 

environment it would be operated in, in the public interest, consistent with railroad 

safety

On September 8, 2000, the FRA determined there was enough information submitted to 

establish that the five Talgo Series VI trainsets could be operated consistent with railroad safety in 

the Pacific Northwest Corridor at speeds up to 79 mph subject to specific conditions tied to the 

review and approval of the train control system. The trainsets and their predecessors (according to 

the FRA) had operated without incident on this corridor since 1994. FRA further concluded that 

the trainsets could also be operated in the public interest and consistent with railroad safety on the 

Los Angeles-Las Vegas route at speeds up to 79 mph.

Amtrak and Volpe had provided and developed information to characterize the 

crashworthiness of the trainsets under the conditions specified. However, given the uncertainty 

related to the crash analysis, risk assessment, and other issues discussed above, the FRA 

determined that the conditions attached to their approval would be necessary to secure a reasonable 

level of confidence that safety would not be compromised.

Final approval was granted by the FRA on March 27, 2009, for the operation of 67 Talgo 

Series VI railcars (five trainsets) having met the conditions discussed above along with the 

following conditions (summarized):
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• Restricted to operations between Eugene, Oregon, and the United States/Canadian 

border near Blaine, Washington, and the route between Los Angeles, California, and 

Las Vegas, Nevada.

• Operations on the Pacific Northwest Corridor were authorized, consistent with other 

railroad safety regulations (including 49 CFR 213.345, “Vehicle/track system 

qualification”) only upon acceptance by the Associate Administrator for Railroad 

Safety/Chief Safety Officer of plans for, and installation of, a train control system 

meeting the requirements of 49 CFR Part 236, “Rules, Standards, and Instructio ns

(Federal Register, 2016, 88060).”

2.6.3 Investigative Hearing

The NTSB conducted an investigative hearing on July 10-11, 2018. One area of focus 

during the hearing was the grandfathered use of the Talgo Series VI trainset. Representatives from 

the FRA, Amtrak, and WSDOT provided expert witness testimony and responded to questions 

from investigators. NTSB investigators wanted to understand if the FRA and Amtrak were 

concerned about the performance of the Talgo Series VI trainset based on the recent evidence of 

how it performed in the DuPont, Washington, accident, and whether the FRA had interest to 

re-examine its decision to grandfather this equipment. The FRA responded by stating it saw no 

reason to reconsider the petition because the items that were covered by the grandfathering 

agreement performed adequately. This assertion is contrary to what NTSB investigators found 

during the investigation. The NTSB found the items covered by the grandfathering agreement did 

not perform adequately. One such item covered by the agreement was the rolling assembly 

retention modification. As discussed earlier, the grandfathering agreement granted by the FRA 

allowed the use of the Talgo Series VI subject to the condition that the railcars were modified by 

applying safety cables between the railcars and bogies (truck assemblies) to resist a minimum total 

longitudinal force of 77,162 pounds to resist separation of the railcar bodies and rolling assemblies. 

This was required because the original design of the rolling assembly between the suspended and 

supported ends of the railcars was primarily held in place by guidance arms and the FRA was 

concerned the rolling assembly could detach during an accident if the railcars came apart.

In this accident five rolling assemblies fully detached, one partially detached and two of 

the detached rolling assemblies were known to be involved in secondary collisions that resulted in 

injury and three deaths. On a Talgo Series VI trainset consisting of 12 railcars, (excluded for this 

discussion are the lead and trailing locomotive) there are 11 rolling assemblies that reside between 

the supported and suspended railcars. Five fully detached rolling assemblies represent a failure 

rate of 45 percent. The NTSB considers a failure rate of this magnitude an unacceptable risk to 

passenger safety. The FRA understood the risk of the Talgo Series VI trainset rolling assemblies 

that could separate during an accident by requiring the modification as a condition to be 

grandfathered. The performance of this modification in this accident demonstrates the 

modification was not successful and the FRA should have serious concerns about the continued 

use of this trainset. The FRA granted grandfathered approval of the Talgo Series VI trainset based 

on several conditions, including the modification of the rolling assemblies to resist separation. 

Should one of those conditions not be met, then the trainset no longer meets the terms of the 

approved agreement. Based on the degraded conditions of the rolling assembly safety straps, the 
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NTSB concludes that the Talgo Series VI trainset designated as Amtrak train 501 was not in 

compliance with the terms and conditions of the FRA’s grandfathering agreement.

Amtrak’s expert witness responded to NTSB’s question during the hearing regarding its 

concern with continued use of the Talgo Series VI trainset from a safety perspective based on its 

performance in this accident by stating they would provide their response later. As of the date of 

this report, no response has been provided from Amtrak.

A grandfather clause is an exemption that allows a design or a system to continue in 

operation that was in use before the implementation of new rules, regulations, or laws. The 

grandfathered system becomes exempt to specific requirements while all other designs or 

operations must abide by the new rules. Depending on specific circumstances, grandfather clauses 

can be implemented in perpetuity, for a specified amount of time, or with specific limitatio ns. 

Regarding the grandfathered approval of the Talgo Series VI trainset, the FRA told investigators 

in the investigative hearing that the FRA’s approval will remain in place for the life of the 

equipment.

The NTSB is concerned that the use of a grandfathering clause for public transportatio n 

systems that do not conform to specific regulatory requirements intended to provide a minimum 

level of safety exposes the public to unnecessary risk. In the case of the Talgo Series VI trainset, 

the grandfathering approval granted by the FRA was based on: an engineering analysis sufficient 

to describe the performance of the static end-strength and its performance in a collision; risk 

mitigation efforts employed in connection with the use of the equipment; and a quantitative risk 

assessment demonstrating the use of the equipment in the service environment it would be operated 

in, was in the public interest, and was consistent with railroad safety. The approach outlined is 

logical in that the elements provide measurable results that allow one to consider the many risks 

that could manifest into significant safety failures, however, in the case of the Talgo Series VI not 

all risks were considered. A reasonable approach would consider the most likely risks associated 

with the design in the environment in which it is used. As discussed above, not all risks were 

considered, such as collisions with freight trains and the service life of a risk mitigating 

modification. In the case of the Talgo Series VI, the analysis and risk assessments were completed, 

mitigating strategies were implemented, and the grandfather application was approved but no 

consideration was undertaken for continued monitoring of the existing risk or risks that might 

develop with aging of the mitigation measures.

There are no regulatory factors in the grandfathering provision that allow the FRA to 

continuously monitor the grandfathered system that was required to contain several mitigating 

modifications. However, nothing prohibited the FRA from monitoring under its existing authority. 

Based on testimony during NTSB’s investigative hearing, the Talgo Series VI trainset is the only 

train in the United States that has an approved grandfathered agreement that allows it to operate 

with railcar-body end-strength that does not meet United States requirements. The NTSB 

concludes that allowing the grandfathering provision to remain in 49 CFR 238.203(d), 

“Grandfathering of noncompliant equipment for use on a specified rail line or lines,” is an 

unnecessary risk that is not in the public interest nor consistent with railroad safety. Therefore, the 

NTSB recommends that the FRA remove the grandfathering provision within 49 CFR 238.206(d) 

and require all railcars comply with the applicable current safety standards.
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2.6.4 Design Life of Talgo Series VI

The NTSB questioned both the FRA and WSDOT during the investigative hearing that 

took place on July 10-11, 2018, about the design life of the Talgo Series VI trainset. The FRA 

expert witness responded that the design life is between 25 and 30 years. When asked what dictates 

the lifespan of a railcar, the FRA indicated there were commercial considerations and material 

fatigue considerations.

Aluminum railcars differ in performance, according to the FRA. Compared to carbon steel, 

aluminum can be more susceptible to accumulating fatigue damage such as cracks in the structure 

to a point that it is no longer economical to continue in service. The NTSB is aware that designers 

must consider the useful life differences in material properties between carbon steel versus 

aluminum, specifically fatigue life. In fact, high-strength aluminum is subject to fatigue failures 

more readily than mild steel at comparable stress levels. In the case of alloyed aluminum, fatigue 

life is considered more carefully for some designs and more importantly, wherever there will be 

vibration, and high stress points.

The Talgo Series VI trainset did experience fatigue failures early in its lifecycle. During its 

investigation, the NTSB learned about four instances of railcar-body cracking “fissures” that were 

discovered with the Talgo Series VI trainsets. Records indicate that in August 2005, just 7 years 

after the trainset entered service, the railcar-body structures started to fail. The fissures first 

appeared on the supported end of the railcars where the rolling assembly towers connected to the 

end frame. During service life, the fissures continued to appear at other locations on the trainset. 

The other location was near the structural area on the end of the railcar where the articulated 

couplers are attached. In all found cases, mitigating repairs were made to stop the fissures from 

propagating and maintain the structures’ intended purpose. This also required increased periodic 

inspections involving Talgo, Amtrak, WSDOT and the FRA. The inspections required contract 

modifications to fund the inspections and added to the existing maintenance cycle. These special 

fissure inspection efforts are expected to continue while the trainsets remain in service.

In a recent inspection that took place in February 2019, the FRA reported that three railcars

from the Mount Olympus trainset were found with new fissures. These newly discovered fissures 

will require additional maintenance mitigation action to prevent further propagation. This trainset 

was the trainset involved in the December 17, 2018, derailment in Vancouver. During the NTSB’s 

examination of this trainset, the fissure inspection was completed by Amtrak personnel with no 

new fissures identified.

During the NTSB’s investigative hearing, the expert witness from WSDOT responded to 

questions about the operating life of the Talgo Series VI trainset. He referred to a fleet management 

plan that considered the design life of the Talgo Series VI trainset. Within the plan, he explained 

there are replacement options proposed based on a design life of 20 to 25 years.

2.6.5 WSDOT’s Fleet Management Plan

The NTSB obtained a copy of WSDOT’s fleet management plan. In it, the plan describes 

WSDOT’s collaborative effort between WSDOT and ODOT to address future equipment needs 

and identifies investment strategies. It documents how demands for Amtrak Cascades equipment 
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and maintenance facilities were being met when the plan was initially developed and how they 

would be addressed once major federally funded infrastructure improvements were completed in 

2017, as well as what equipment and maintenance needs must be met through the year 2037 to 

ensure the continued growth of the Pacific Northwest’s intercity passenger rail system.

The plan included a life-cycle analysis that predicted an optimum life of the trainset based 

on economic factors such as annual maintenance costs, overhauls, and the availability of financing 

for fleet replacement. The analysis does not have any consideration for the engineering limits of 

the design life of the Talgo trainset nor any considerations to provide safe reliable transportatio n 

that is in the public’s interest. One could make the argument that overhauls could serve as the basis 

for consideration of engineering design limits or safety, when it comes to a railcar-body that 

develops fissures during its lifecycle and the increasing costs associated with mitigations. The 

NTSB recognizes the economic realities for owning, operating, and planning for future 

transportation needs but these economic interests must be equally balanced with the safe operation 

of the system to include procuring equipment that meets or exceeds the current passenger safety 

standards in the United States.

A representative from WSDOT testified at the NTSB investigative hearing on this accident 

that the average service life of the Talgo trainsets is between 20-25 years. This statement is also 

included in WSDOT’s Fleet Management plan. This confirms that WSDOT is currently operating 

a trainset that is at or near the end of its useful life—a trainset that lacks structural protections and 

does not meet United States standards. WSDOT is now aware and continues to operate a Talgo 

Series VI trainset design that does not provide adequate protection to passengers in the event of a 

high-energy derailment or collision. After an overall evaluation of this trainset design, the NTSB 

concludes the Talgo Series VI trainset does not meet current United States safety standards and

poses unnecessary risks to railroad passenger safety when involved in a derailment or collisio n. 

Therefore, the NTSB recommends that WSDOT discontinue the use of the Talgo Series VI 

trainsets as soon as possible and replace them with passenger railroad equipment that meets all 

current United States safety requirements.

2.6.6 Lead Locomotive

There were no visual separations of the corner and collision posts, or visual separations or 

ruptures of the welded seams. Both side-entry doors of the engineer’s cab and the machine room 

access door were operable. The underframe was locally deformed, but the structural condition was 

intact. The CEM in the front and rear coupler was not activated. Both trucks and their retention 

mechanisms remained intact and attached to the locomotive. The fuel tank and the fuel tank inlet 

were not compromised because of this derailment. The right side of the locomotive exhibited 

nonstructural compromising sidewall damage consistent with the locomotive being on its side.

The operating cab windshield was destroyed; however, the laminated safety glass feature 

prevented the shattered glass from separating into pieces. Damage to the interior of the operating 

cab was constrained primarily to the leading end, most notably at and above the front glazing 

(windshield). The vertical space of the cab interior was reduced to about 19 inches between the 

operator’s desk and the ceiling, and to 66 inches from the floor to the ceiling. The height above 

the seats was reduced to 66.5 inches.
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This investigation determined locomotive WTDX 1402 (1) was constructed to meet 

crashworthiness standards as prescribed by FRA regulations and AAR standards. The NTSB 

concludes that the lead locomotive’s crashworthiness design and CEM features minimized the 

severity for injuries and fatalities to the train crew by performing as intended in this accident.

2.7 Survival Factors

The survival factors investigation focused on issues relating to passenger injuries, the 

postaccident evacuation process, and emergency response communications. The analysis will 

discuss the unintentional rotation of the train seats that led to passenger injury and the reduction

in the available egress space. The rotation of the train seats also compromised the occupant 

protection afforded by compartmentalization by allowing occupants to travel farther within the 

train railcar, thus increasing the likelihood of injury. In addition, the analysis focused on the 

difficulties encountered by the passengers during the postaccident evacuation caused by the lack 

of emergency lighting and the lack of the required HPPL material in the signage regarding exit 

controls and manual release levers. Lastly, the investigation examined the communicatio n 

operations of the emergency responders and the issues related to the lack of interoperability 

between the communications systems for the responding agencies.

2.7.1 Emergency Lighting

After the derailment, the interior of the railcars lost all power. This forced passengers to 

make their way through the darkened railcars to egress points. The ambient lighting was 

insufficient to assist the passengers as they attempted to evacuate the train. Use of egress points 

and emergency exits were hampered by the lack of emergency lighting. Passengers were unable to 

read instructional signs that provided information regarding the operation of exit controls and 

manual release levers. In several instances, the passengers were unable to properly manipulate the 

exit controls which delayed their escape from the railcar. The lack of lighting added to the 

confusion and the difficulty in evacuating the railcar.

First responders reported that the lack of lighting complicated the rescue efforts. First 

responders inadvertently walked over victims lying on the floor because of the inability to see 

them. The lack of lighting made it difficult for emergency responders to see and avoid obstacles 

and other dangers in the damaged railcars. The Talgo trainset does not possess adequate emergency 

lighting in the event of the railcars separating in an accident. The batteries are located at the front 

of the train in the power railcar, and in the baggage railcar, located to the rear. Separation of the 

railcars, as occurred in this derailment, causes a disruption in the power to all the railcars. The 

NTSB concludes that after the Talgo trainset separated from the power cars, there was no power 

to the train for emergency lighting which hampered the ability of passengers to evacuate the train 

and the ability of the first responders to conduct rescue operations within the railcar. The NTSB 

further concludes that the lack of emergency lighting hampered the ability of passengers to 

evacuate the train and the ability of the first responders to conduct rescue operations within the 

railcar.

Following the 1996 train accident between a Maryland Area Regional Commuter train and 

an Amtrak train near Silver Spring, Maryland, that resulted in the deaths of 11 people, the NTSB 
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issued recommendation R-97-17 to the FRA regarding emergency lighting on passenger trains

(NTSB 1997):

Require all passenger railcars to contain reliable emergency lighting fixtures that 

are each self-contained independent power source and incorporate the requirements 

into the minimum passenger railcar safety standard. (R-97-17)

In 1999, the FRA issued regulations that required emergency lighting for new passenger 

railcars. The FRA regulations stated that minimum levels of emergency lighting must be provided 

adjacent to doors intended for emergency egress and along aisles and passageways for new 

equipment. However, the Talgo trainset was manufactured prior to the implementation of this

standard.

As discussed in section 1.13.9, the FRA amended the requirement for emergency lighting 

requirements for passenger railcars in 49 CFR 238.115, “Emergency Lighting,” in November 

2013. The amended rule required that equipment ordered before September 8, 2000, have batteries 

in each railcar for emergency lighting should they be disconnected from the power source. The 

Talgo trainset is required to comply with 49 CFR 238.115 (b)(1-2) that states the equipment should 

comply with APTA standard PR-E-S-013-99, Rev. 1. The rule stipulates that no later than 

December 31, 2015, at least 70 percent of each railroad’s passenger railcars that were ordered prior 

to September 8, 2000, and placed in service prior to September 9, 2002, comply with the 

emergency lighting requirements. Amtrak requested and was denied a waiver of compliance by 

the FRA. As of the publication of this report, the Talgo trainset does not have required emergency 

lighting installed. Plans have been made for the modification; however, the trains are still without 

this essential safety feature. The Talgo equipment did not meet the emergency lighting standards 

outlined in 49 CFR Part 238, “Passenger Equipment Safety Standards.” The NTSB is concerned 

with the lack of compliance of this much-needed safety feature on all rail passenger equipment. 

Information provided in the FRA’s denial response to Amtrak’s waiver request show that there are 

more than 1,000 passenger cars of various types that do not meet the current requirements. 

Therefore, the NTSB recommends to the FRA to use its authority and compel all commuter and 

passenger railroads to meet the requirements outlined in 49 CFR Part 238 without delay, such that 

in the event of a loss of power, adequate emergency lighting is available to allow passengers, 

crewmembers, and first responders to see and orient themselves, identify obstacles, safely move 

throughout the railcar, and evacuate safely.

2.7.2 Exit Controls and Manual Release Mechanism Signage

The loss of power in the railcars and the failure of the system to provide adequate 

emergency lighting resulted in several passengers being unable to properly operate the exit controls 

for the railcar doors and delayed their evacuation from the train. The postaccident examination of 

the railcar revealed that the instructional signs/stickers were present as required by regulation on 

emergency exit windows, over door exit controls, and manual release mechanisms. However, the 

instructional signs located over the door exit controls and manual release mechanisms lacked the 

required HPPL material which would have allowed them to be visible and read by the passengers 

in the low-light or no-light environment. The passengers’ inability to read the signs caused the 

failure to correctly perform the steps required to operate the doors, thus delaying their evacuation 

from the train. The NTSB concludes that the instructional signs located above the railcar door exit 
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controls and manual release mechanisms lacked the required high performance photoluminescent

material or suitable alternative that would have allowed them to be visible and read in low-light or 

no-light environments. Further, the NTSB concludes that the inability of the passengers to see and 

read the instructional signs regarding the exit controls and manual release mechanisms resulted in 

the inability of the passengers to use that point of egress for escape and delayed their evacuation 

from the train.

2.7.3 Compartmentalization

The primary objectives of crashworthiness are to preserve space for occupants to ride out 

the accident and to limit, to survivable levels, the forces imparted to those occupants. Train seats 

are placed reasonably close and at a distance to reduce the occupant’s amount of fore and aft travel 

within the railcar during an accident. By limiting how far occupants can travel within the interior 

and by providing strategic padding, the forces imparted to a train passenger could be survivab le. 

By comparison to highway crashes, the deceleration experienced by a train occupant is generally 

far less than that experienced by passengers in automobiles. 

A paper published by Volpe titled “Reducing the Harm in Rail Crashes: Analysis of Injury 

Mechanisms and Mitigation Strategies” examined crashworthiness and passenger injuries. Volpe 

determined that compartmentalization and the application of an energy-absorbing material to the 

seatbacks in the railcars increased passenger safety. The paper found that many nonfatal injuries 

were caused by passengers striking the seatbacks with significant force or failing to remain upright 

in their seats. Maintaining the integrity of the railcar interior, to include the position of the train 

seats, provides significant occupant protection.

On September 12, 2008, a passenger train and a freight train collided head-on in the 

Chatsworth district of Los Angeles, California, with each train initially traveling at more than 40 

mph (NTSB 2010). Twenty-four passengers and one crewmember were killed on the passenger 

train, and about 138 train occupants were injured, many severely. The passenger train cars operated 

by Metrolink did include compartmentalization features that mitigated many potential injuries. 

Forward-facing row-to-row seats in the Metrolink cars provide a relatively high level of safety. 

The seats are reasonably close together, with a seat pitch of about 32 inches, which places the front 

of the occupant about 1.5 feet away from the rear of the adjacent seat back. This seating 

configuration compartmentalizes the occupants between rows of seats, with minimal distance to 

travel in free-flight during a collision, which minimizes the secondary impact velocity. The 

fiberglass seat back is fairly rigid, but injuries experienced by passengers in this configuration are 

usually not extremely severe because the secondary impact velocity is moderate.

2.7.4 Train Seat Design

In the Talgo passenger railcars, a select number of train seats and seat pairs are designed 

to rotate. These rotating seats are equipped with a seat-latching mechanism that locks the seat into 

place to prevent unintentional rotation. Rotation of the seat is normally accomplished by pressing 

the lock-pedal and pulling on the outboard armrest. The seat is locked into place by pushing sharply 

toward the wall and allowing the lock-pedal to snap into place.
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During the derailment of train 501, several railcars experienced the inadvertent rotation of 

train seats. This occurred in six of the passenger railcars and resulted in injury to several passengers 

and restricted the available aisle space for passenger egress. The displacement of the train seats 

minimized the effectiveness of compartmentalization, which uses the railcar design to provide 

occupant protection. In railcar AMTK 7423 (9), eight rows of train seats rotated during the 

derailment. The right side of the coach railcar sustained structural damage from the collision and 

subsequent penetration of the side of the aluminum railcar by the metal overpass bridge railing. 

On that side, four rows of seats rotated. Despite only sustaining minimal damage to the left side of 

the railcar, four rows of seats were also displaced or rotated during the derailment. The displaced 

seats partially obstructed the aisleway. Railcars AMTK 7420 (12) and AMTK 7422 (10) received 

only moderate damage to the exterior of the railcars and little or no damage to the interior during 

the derailment. However, both railcars experienced the rotation of multiple rows of seats. Railcar 

AMTK 7421 (11), sustained extensive damage in the derailment to include penetrating damage to 

the right side of the railcar. Several rows of seats rotated at the location where the railcar sidewall 

was penetrated and pushed inward. Postaccident examination of railcar AMTK 7554 (4) found that 

three seats were displaced from their original position, including two seats that were not designed 

to rotate.

A postaccident examination of the train seat latching mechanism was performed. Several 

of the seat latching mechanisms were examined and found to be operational. However, despite no 

evidence of mechanical failure, seats in the railcars rotated during the derailment. No definitive 

evidence could be found to support a finding of mechanical defect or the improper application of 

the latching mechanism by the train crew. The rotation of the seats caused injuries to seated 

passengers and decreased the available egress space in the passenger aisleways. 

A previous investigation into the rotation of railcar seats and occupant injuries had been 

conducted by the FRA in 2007 (FRA 2013a). The investigation into the collision between an 

Amtrak passenger train and a Norfolk Southern freight train revealed that several of the coach 

railcars experienced rotation of train seats despite the railcars sustaining minimal damage. The 

investigation found that the rotation of the train seats was likely caused by the collision forces 

experienced by the railcar during the accident. The seat latching mechanisms were unable to 

overcome these forces resulting in the rotation of the train seats. The investigation was unable to 

definitively determine the cause of the rotation of the train seats. There was no evidence that the 

seat latching mechanism failed or that the seat latches were improperly engaged by the crew. The 

examination of the railcar seats by the investigators revealed that several of the rotated seats 

showed signs of impact with the railcar occupants. The investigators were unable to determine 

whether the rotation of the seats caused the injury to the occupant or whether the unrestrained 

occupant caused the rotation of the train seat. The NTSB concludes that the rotation of the train 

seats (1) minimized the effectiveness of compartmentalization by allowing passengers to travel 

greater distances within the railcar during the accident, (2) caused injury to several passengers, (3) 

decreased the available aisleway space for passenger egress. Therefore, the NTSB recommends 

that WSDOT, Amtrak, and ODOT develop and implement a program by which all railcar seats 

that are designed to rotate be checked for proper positioning and securement in place before the 

railcar can be placed into or returned to passenger carrying service.

The securement of passenger train seats against inadvertent rotation has been a recognized 

safety issue since 1990, when the NTSB investigated an Amtrak train derailment in Batavia, Iowa
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(NTSB 1991). On January 14, 1992, the NTSB issued Safety Recommendation R-91-71 to Amtrak

urging the railroad to implement procedures for on-board personnel to periodically check 

passenger seats, while enroute, for unlocked anti-rotational devices and take action to ensure the 

seats are functional. The recommendation was classified “Closed—Acceptable Action” on 

May 22, 1992, after Amtrak provided a copy of newly issued instructions to on-board personnel 

and transportation crews to check for unlocked anti-rotational devices and to ensure seats are 

functional. The NTSB also issued Safety Recommendation R-91-72 to inspect all Trison seat locks 

to ensure that all are functional which was classified “Closed—Acceptable Action” on June 10, 

1993, after Amtrak reported that it had completed a one-time inspection of all Trison seat locks.

The NTSB’s investigation of the August 5, 1997, derailment of Amtrak train 4 near 

Kingman, Arizona, found multiple seat assemblies with their rotational locking mechanisms not 

engaged, and as a result, several passengers sustained injury (NTSB 1998). On September 16, 

1998, the NTSB issued Safety Recommendation R-98-56 to the FRA and Safety Recommendatio n 

R-98-61 to Amtrak to install a positive seat securement system to prevent disengagement and 

undesired rotation in all new passenger cars purchased after January 1, 2000, and to incorporate 

the system into existing passenger cars when they are scheduled for overhaul. In October 1996, 

the FRA released a report titled, “Crashworthiness Testing of Amtrak’s Traditional Coach Seat: 

Safety of High-Speed Ground Transportation Systems,” which discussed research conducted by 

Volpe, on behalf of FRA (FRA 1996). According to this report, the seat securement systems were 

tested and determined to be sufficiently strong to withstand the occupant loads. On July 19, 2012, 

based on information provided by Amtrak in response to Safety Recommendation R-98-61 and 

the completed Volpe study, the NTSB classified Safety Recommendation R-98-56 

“Closed--Acceptable Alternative Action.” In response to Safety Recommendation R-98-61, on 

June 23, 2000, Amtrak said that it reviewed the merits of this recommendation and determined 

that Amtrak’s existing positive seat securement system was adequate to prevent undesired rotation. 

At that time, Amtrak said that it continued to concentrate its efforts with standard procedures to 

ensure that all seat assemblies are secure, and that Amtrak had redundant checks in place prior to 

departure and enroute. Coach cleaners, mechanics, and all staff members that turn seats as part of 

their duties should make sure that all seats are returned to their proper position and in the "locked" 

position. Employees inspecting a train just prior to departure are required to check and ensure all 

seat assemblies are secured. Additionally, all crewmembers have the responsibility to periodically 

inspect seats during operations. Based on Amtrak’s alternative measures to prevent undesired seat 

rotations, on December 5, 2000, the NTSB classified Safety Recommendation R-98-61 

“Closed--Acceptable Alternate Action.”

Although the NTSB believed that the procedures that Amtrak implemented to ensure that 

antirotational locking mechanisms on seats were being routinely checked, and that Volpe’s study 

found that the locking mechanism was sufficiently strong to withstand occupant loads, the results 

of this accident again found that seats were not adequately secured against rotation during a 

derailment accident sequence, and that the seat rotations contributed to the injuries sustained and 

impeded passengers from escaping the railcar after the accident. The NTSB was unable to 

determine if the procedures that Amtrak developed in response to Safety Recommendatio n 

R-91-71, and which were the basis for closing Safety Recommendations R-98-61 and R-98-56 to 

the FRA, were being used in the train involved in this accident. The NTSB concludes that existing 

procedures and design standards for antirotational seat locking mechanisms do not adequately 

protect passengers in accidents. Therefore, based on the findings of this accident, the NTSB 
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recommends that the FRA reevaluate existing seat securement mechanisms and their susceptibility 

to inadvertent rotation, to identify a means to prevent the failure of these devices to maintain seat 

securement.

2.7.5 Passenger Ejection and Injuries

During the derailment, AMTK 7424 (8) became separated from the attached railcars in the 

front and to the rear. AMTK 7424 (8) left the track and flipped end over end, overturning and 

sliding down the grassy embankment adjacent to I-5. The railcar entered the roadway, striking 

several vehicles before sliding to a stop. During the derailment and subsequent collisions with the 

bridge and roadway vehicles, the structural integrity of the railcar was compromised and several 

of the railcar windows were lost. Five passengers were ejected through the window openings and 

onto the interstate. All five passengers sustained injury resulting from the ejection.

Title 49 CFR 238.215(b) addresses the rollover strength of passenger railcar roofs. The 

requirements for the design of passenger railcars include their ability to maintain structural 

integrity and resist structural collapse into the occupant space during a rollover event. The 

regulation does not address railcar deformation or buckling that could adversely affect the 

structural support for the railcar windows. In this accident, AMTK 7424 (8) was exposed to 

secondary collision and crush forces that exceeded its design specifications and failed to retain 

passengers within the railcar. The deformation of the railcar structure during the accident sequence 

permitted the loss of the railcar windows. The loss of these railcar windows provided the openings 

through which passengers were ejected.

AMTK 7421 (11) separated from its lead railcar and after derailing came to final rest 

hanging from the trailing railcar off the bridge overpass. Because of the previous separation, an 

opening was created at the front of the railcar in the vestibule area. One passenger was partially 

ejected from the railcar when she was thrown through the opening during the derailment. The 

partially ejected passenger received injuries during the ejection. Therefore, the NTSB concludes 

that the failure of the articulated connections defeated the compartmentalization feature of AMTK

7421 (11) and provided a pathway for passenger ejection. The NTSB further concludes that when 

the articulated connections failed, it resulted in a secondary collision that caused railcar AMTK 

7424 (8) to roll over onto its roof and collapse its structure which dislodged the windows and 

allowed passengers to be ejected.

An unoccupied child car seat was thrown out of the railcar through the same opening as 

the partially ejected passenger. The seats in the railcar were not equipped with seatbelts and did 

not possess securement points or straps for the child car seat. Because of the inability to secure the 

child car seat, it was placed on top of one of the tables in the railcar. The table was located at the 

end of the railcar, adjacent to the vestibule where the opening was created when the articulated 

connections failed.

The FRA-sponsored research into occupant protection for passenger railcars and developed

standards based on testing of anthropomorphic dummies ranging from a 5th percentile female 

(height 5 feet, weight 110 pounds) to the 95th percentile male (height 6 feet 1 inch, weight 222 

pounds). Additional dynamic accident simulations were performed utilizing anthropomorp hic 

dummies that ranged from the 50th percentile male (height 5 feet 7 inches, weight 172 pounds) to 
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the 95th percentile male (FRA 2002) (FRA 2003). The tests did not account for smaller passengers, 

such as children or small-statured adults. Thus, smaller passengers, especially children, may not 

be afforded the same level of protection as adults, due to their size and their inability to control 

their displacement during an accident. Though significant research has been conducted regarding 

occupant protection for children in highway vehicles, less research has been conducted on 

occupant protection through compartmentalization in aviation and rail transportation. The NTSB

concludes that limited research has been conducted into the effectiveness of compartmentalizatio n 

in passenger railcars for individuals that fall outside of the testing standard range, such as small 

children. Therefore, the NTSB recommends the FRA conduct research into the effectiveness of 

occupant protection through compartmentalization for passengers whose size (including children) 

is not within the current range of anthropomorphic passenger sizes in FRA standards.

In today’s society, there is a public expectation of a certain level of safety when using car 

seats when traveling. Small children in unrestrained car seats may experience unexpected or 

uncontrolled movement when traveling by train due to sudden or unexpected decelerations which 

could result in an injury or worse. Although there was not an injury associated with the child’s seat 

ejecting from AMTK 7421, the outcome represented a likely tragic event. The unrestrained car 

seat was ejected from the railcar at its rear door during the derailment after the articulated 

railcar-to-railcar connection failed. The NTSB supports the use of child safety seats and is

concerned that the inability to anchor a child safety seat lessens its safety. The NTSB concludes 

that the inability to secure child safety seats in a passenger train results in an undue risk to children 

due to uncontrolled or unexpected movements during a derailment or collision.

Amtrak’s current policy allows the use of a full-size seat, if available, for small children 

under the age of 2. If no full-size seat is available, they must be carried on the lap of a paying adult. 

There are currently no features on Amtrak passenger trains that would allow small children in car 

seats to be restrained. In this accident, the parents who brought their child in a car seat reported 

that they were unaware that the train would not have securement straps necessary to belt the car 

seat into one of the seats in the railcar. Subsequently, the car seat containing the child was placed 

on top of a table during the journey. Although the child was removed from the car seat shortly 

before the time of the accident, during the derailment, the unrestrained car seat was ejected out of 

AMTK 7421 (11). The NTSB believes that the parent’s expectation that suitable restraints for 

securing the child seat would be available in the railcar is representative of what many parents 

traveling with small children may believe. The NTSB concludes that Amtrak should develop a 

policy for safely accommodating parents traveling with small children restrained in child safety 

seats. Therefore, the NTSB recommends that Amtrak develop policies for the safe use of child

safety seats to prevent uncontrolled or unexpected movements in passenger trains and provide 

customers with guidance for securing these child safety seats.

The NTSB has been concerned about passengers being ejected through window openings 

for more than 40 years. In 1972, the NTSB noted that window ejections accounted for a large 

portion of passenger fatalities (NTSB 1972). Because of this, the NTSB made the following 

recommendation to the FRA:

In establishing near-future safety standards for railroad and rail rapid-transit 

passenger railcars, give priority to the problem of ejection of passengers through 

large side windows. Regulations should be promulgated on realistic performance 
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tests. This source of fatalities, even though small in number, is of such a large 

proportion among passenger fatalities as to warrant action prior to the issuance of 

the Mechanical Standards. (R-72-32) 

The FRA had introduced improved safety measures for passenger railcars between 1972 

and 1985. The NTSB recognized these improvements and on July 29, 1985, Safety 

Recommendation R-72-32 was classified “Closed—Acceptable Action.” However, since 1985 the 

NTSB has investigated several accidents that still have window issues. Window separations 

occurred in the December 1, 2013, accident of a Metro-North passenger train near Bronx, New 

York (NTSB 2014). That train, which derailed at 82 mph, consisted of seven passenger railcars

and a locomotive. Four passengers were killed, and 57 passengers and 4 crewmembers were 

injured. In that case, the NTSB found that a contributing factor to the severity of the accident was 

the loss of windows that resulted in the fatal ejection of four passengers from the train. As a result 

of that accident, the NTSB issued the following recommendation to the FRA on December 2, 2014:

Develop a performance standard to ensure that windows (e.g., glazing, gaskets, and 

any retention hardware) are retained in the window opening structure during an 

accident and incorporate the standard into 49 Code of Federal Regulations (CFR) 

238.221 and 49 CFR 238.421 to require that passenger railcars meet this standard. 

(R-14-74) 

On March 25, 2015, the FRA responded that it was developing a research program to test 

all safety aspects of window systems, including window retention and passenger containment 

during potential accident scenarios, as well as emergency egress, rescue access, and impact 

resistance requirements. The FRA also said that it needed to obtain more information before 

determining a research approach on this issue due to the competing expectations for railcar window 

performance. The FRA expected this research to provide performance data on window retention 

and passenger containment, evaluate existing and potential designs for window systems, and 

investigate practical testing metrics and methodologies to assess and quantify containment 

capabilities. Once this research was complete, the FRA planned to assess the influence of design 

methodologies that enhance containment capabilities while preserving the ability of window 

systems to provide required emergency egress and rescue access without compromising other 

safety purposes. When the research program was completed, the FRA would determine proposed 

regulatory changes that are reasonable and practical.

On May 12, 2015, less than 2 years after the Metro-North derailment, Amtrak train 188 

derailed near Philadelphia, Pennsylvania (NTSB 2016). Four passengers were ejected and killed. 

The NTSB accident report discussed the FRA’s current passenger equipment safety regulatio ns, 

which did not require protection from lateral forces caused by derailments and overturns. The 

injuries in the Amtrak train 188 accident illustrated the need for railcar safety design standards to 

address such forces. The NTSB’s report about the Amtrak train 188 accident concluded that,

although the passenger equipment safety standards in 49 CFR Part 238 provide some level of 

protection for occupants, the current requirements did not ensure that occupants are protected in 

some types of accidents, and that railroad occupant safety research and regulations should better 

reflect the different types of accidents that were occurring and employ a systematic approach that 

considers the causes of injury during derailments in which occupants may be thrown or struck by 
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loose objects. As a result, the NTSB issued two recommendations to the FRA addressing 

improvements needed to the FRA’s occupant protection standards:

Conduct research to evaluate the causes of passenger injuries in passenger railcar 

derailments and overturns and evaluate potential methods for mitigating those 

injuries, such as installing seat belts in railcars and securing potential projectiles. 

(R-16-35) 

When the research specified in Safety Recommendation R-16-35 identifies safety 

improvements, use the findings to develop occupant protection standards for 

passenger railcars that will mitigate passenger injuries likely to occur during 

derailments and overturns. (R-16-36) 

The FRA responded to these recommendations on August 23, 2017, indicating that through 

its Rail Safety Advisory Committee (RSAC) Passenger Safety Working Group, it had continually 

supported numerous research activities evaluating the causes of passenger injuries in various train 

derailment and collision scenarios. The FRA said that its effort supported new industry standards 

and federal regulation where necessary, including a notice of proposed rulemaking (NPRM) 

updating and supplementing its passenger equipment safety standards. The FRA went on to discuss 

its belief that, unlike accidents in the automobile and air transportation modes, adding seat belts in 

passenger railcars was not an effective way to increase safety because the purpose of seat belts 

was to allow occupants to survive the deceleration of the volume within which they are contained. 

According to the FRA, passenger rail coaches experience a peak deceleration of one-fourth that of 

automobiles during a collision and, therefore, the interior of a typical passenger railcar provides a 

level of protection to passengers, without the need for seat belts, at least as effective as the 

protection provided to automobile and air transport passengers.

The FRA also wrote in its August 23, 2017, letter, that it had extensively evaluated the 

effectiveness and practicality of available occupant protections such as seat belts, and it concluded 

that focusing efforts on passenger containment and interior attachment integrity, and ensuring that 

passengers survive secondary impacts, were the most effective methods of preventing and 

mitigating passenger injuries. The FRA indicated that it would continue to support and perform 

research to evaluate the causes of passenger injuries in train derailments and collisions as specific 

issues arise, but it did not plan to initiate a separate new research program.

The NTSB does not agree with the FRA that its current research program and regulatio ns 

effectively address protecting passengers in railcars involved in derailments and overturns. In the 

span of 4 years, the NTSB has investigated three major railroad accidents involving passenger 

railcar derailments that resulted in significant lateral acceleration, for which containment did not 

adequately protect the 11 passengers killed after being ejected from the railcars. In addition, 

containment did not fully protect the over 300 passengers hospitalized in these accidents. The 

NTSB concludes that this accident shows the need for the FRA to take action on Safety 

Recommendations R-16-35 and -36, which addressed the FRA’s occupant protection standards.

Therefore, the NTSB reiterates Safety Recommendations R-16-35 and -36 to the FRA, which are 

reclassified “Open—Unacceptable Response.”
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2.7.6 Communications

The emergency response to the derailment involved multiple agencies from three different 

jurisdictions. The jurisdictions include JBLM and Pierce and Thurston Counties. The train 

derailment occurred within Pierce County. JBLM has concurrent jurisdiction with Pierce County 

in DuPont, Washington. The base’s Emergency Communications Operation is controlled by the 

DOD and operates on a different radio frequency than the other emergency agencies within Pierce 

County. JBLM’s communications system is also not compatible with the emergency 

communication system used by Thurston County, the adjacent jurisdiction to the south. The lack 

of interoperability between the various communication operations resulted in confusion by the 

emergency responders on the scene regarding command and the inability to effectively coordinate 

the rescue efforts among the various responding agencies and jurisdictions.

Because of the inability of the various fire and rescue agencies to communicate with one 

another over a common radio frequency, the command officers for each jurisdiction had to conduct 

operations face-to-face. The various command officials were required to sit together in the same 

automobile to establish a unified command. This was an inefficient method of conducting a large 

operation such as a mass casualty incident. The lack of effective communications resulted in 

established protocols not being followed which led to the failure to properly account for personnel 

on the scene, the dispatch of additional resources from a neighboring jurisdiction that was a greater 

distance away despite appropriate units being available that were closer to the scene and within 

the same county. Several members of the fire department characterized their own rescue efforts as 

“freelancing” resulting from the lack of an identified command structure. Multiple hospitals were 

“stood up” or alerted due to confusion created by the lack of communication and coordinatio n 

between the various agencies, jurisdictions, and JBLM, who was ultimately in command of the 

incident. 

The various law enforcement agencies that participated in the operation had established a 

separate command post that could not coordinate its efforts with the fire department because the 

agencies could not communicate directly with one another. Attempts to combine the two separate 

command posts into one unified command post were unsuccessful. The NTSB concludes that since 

there was no common incident command radio channel between fire and rescue agencies, law 

enforcement, and emergency management, the emergency response lacked efficient coordinatio n.

2.7.7 Postaccident Activity

The lack of interoperability between JBLM’s communications system and that of the other 

responding agencies was known prior to the derailment. JBLM’s director of emergency services 

had been working with the DOD to improve his agency’s ability to communicate with surrounding 

jurisdictions but the project had not been completed at the time of the accident. The NTSB 

concludes that the lack of interoperability of the emergency communications system used by 

JBLM resulted in poor communications that adversely affected the coordinated rescue effort.

Following the accident, JBLM purchased the necessary radios that will allow communication with 

local emergency response agencies. JBLM also coordinated with adjacent jurisdictions to establish 

regional interoperability channels for a multiagency response. When completed, JBLM will have 

interoperability with all emergency responders in the region.
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The NTSB realizes that there are other military facilities that coordinate emergency 

services with local civilian agencies. The NTSB concludes that incompatible radio frequencies or 

similar communication issues may exist at other locations where military and civilian agencies 

coordinate their emergency response. Therefore, the NTSB recommends the DOD Fire and 

Emergency Services Working Group: (1) Identify all military installations that provide emergency 

services to areas outside of their installations, make them aware of this accident, and determine the 

effectiveness of the communications system between that military installation and the adjacent 

jurisdictions. (2) Implement a plan to address any deficiencies with interoperability caused by the 

incompatibility between the DOD communications system and that of adjacent civilian agencies.
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3.Conclusions

3.1 Findings

1. None of the following was a factor in this accident: the mechanical readiness of the train, 

the condition of the track or signal system, the weather, cell phone use, medical conditions 

of the Amtrak engineer; use of alcohol or other drugs, fatigue, or any impairment or 

distraction.

2. This accident has demonstrated the value of image and audio data for the accident 

investigation and development of safety recommendations.

3. The Federal Railroad Administration has demonstrated an unwillingness to implement the 

recommendations and regulation that would require inward-facing video and audio devices 

that are critical to accident investigations and improving safety on our nation’s railroads.

4. Inward-facing recorders with both image and audio capabilities can increase the 

understanding of the circumstances of an accident, and, ultimately, provide greater 

precision in safety recommendations and subsequent safety improvements.

5. Had the positive train control system been fully installed and operational at the time of the 

accident, it would have intervened to stop the train prior to the curve, thus preventing the 

accident.

6. The Amtrak qualification program for the Point Defiance Bypass did not effectively train 

and test qualifying crewmembers on the physical characteristics of a new territory.

7. Amtrak did not provide sufficient training on all characteristics of the Charger locomotive.

8. The engineer’s unfamiliarity with, and fixation on, the audible and visual alerts associated 

with the overspeed alarm reduced his vigilance of events outside the locomotive moments 

before the accident.

9. Engineers could better master the characteristics of a new locomotive with the use of 

simulators.

10. A systematic approach to training would have aided Amtrak managers in recognizing the 

challenge of operating new equipment on new territories.

11. Supplemental warning plaques, such as distance ahead plaques, or other types of 

conspicuous signs strategically positioned after an advance warning speed reduction sign 

would provide enhanced visibility as an added level of safety for operating crews of 

passenger and freight trains.

12. Crewmembers qualifying on a territory can and should play an active role in establishing 

and maintaining safe train operations.
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13. Had the Washington State Department of Transportation, Central Puget Sound Regional 

Transit Authority, Amtrak, and the Federal Railroad Administration been more engaged 

and assertive, and had clearly defined roles and responsibilities during the preparation of 

the inaugural service, it would have been more likely that safety hazards, such as the speed 

reduction for the curve would have been better identified and addressed.

14. The Federal Railroad Administration did not use its authority provided under the Fixing 

America’s Surface Transportation Act to approve speed limit action plans with conditions 

to require inclusion of planned and under-construction alignments owned or operated by 

railroads and require periodic updates to railroads’ speed limit action plans, which led to 

no speed limit action plan being developed.

15. The Federal Railroad Administration should have ensured that speed limit action plans 

include new or updated routes owned or operated by railroads, using its authority in the 

Fixing America’s Surface Transportation Act.

16. Central Puget Sound Regional Transit Authority did not update the timetable on its 

Lakewood Subdivision to identify the curve at milepost 19.8 as a crew focus zone, which 

would have helped to mitigate the overspeed derailment risk.

17. Amtrak failed to update the operating documents prior to starting revenue service which 

would have highlighted the speed reduction at the accident curve.

18. Central Puget Sound Regional Transit Authority’s omission of the final activities of the 

certification process resulted in the failure to control the identified hazardous condition of 

an overspeed derailment at the accident curve.

19. Central Puget Sound Regional Transit Authority failed to implement effective mitigatio ns 

in lieu of positive train control to control the hazard at the accident curve.

20. There was no requirement for the Washington State Department of Transportation, Central 

Puget Sound Regional Transit Authority, or Amtrak to provide additional protection for 

the accident curve.

21. Because the Federal Railroad Administration did not act on the recommendation to add 

technology to assist engineers in determining their location, an opportunity to improve 

safety was overlooked.

22. Washington State Department of Transportation should have provided greater oversight of

Central Puget Sound Regional Transit Authority’s safety certification process.

23. The Federal Railroad Administration’s current requirement to review, but not approve, 

system safety program plans does not achieve the level of safety oversight expected from 

the Federal Railroad Administration.

24. Without positive train control and the lack of oversight to implement mitigations, there was 

an increased safety risk to the traveling public.
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25. Amtrak did not take an active enough role in reviewing safety aspects during the 

preparation of the Point Defiance Bypass to ensure a safe operation.

26. Amtrak failed to assess, evaluate, and act upon readily identifiable safety hazards to ensure 

the safety of the Point Defiance Bypass for the traveling public and its own train crews.

27. Amtrak needs to implement a safety management system on all of its operations whether 

internal, host railroad, or in states that own infrastructure over which Amtrak operates.

28. The repeated postponement of Title 49 Code of Federal Regulations Part 270, System 

Safety Program, has delayed needed safety improvements for the passenger rail industry, 

rail employees, and the traveling public.

29. The use of risk assessments to identify, mitigate, and control risk on new and upgraded

service will increase the level of safety to Amtrak operations over all territories.

30. The Talgo Series VI passenger railcar AMTK 7424 (8) did not provide adequate occupant 

protection after its articulated connections separated, resulting in complex uncontro lled 

movements and secondary collisions with the surrounding environment which led to 

damage so severe to the railcar body structure, that it caused passenger ejections.

31. The failure of the articulated connections of both Talgo Series VI passenger railcars

AMTK 7422 (10) and AMTK 7504 (7), the detached rolling assembly from AMTK 

7422 (10) and its secondary collision with AMTK 7504 (7) directly resulted in three 

fatalities and two partially ejected passengers who had been traveling in AMTK 7504 (7).

32. The safety straps used for the Talgo Series VI trainset rolling assembly retention 

modifications were degraded due to their use in exposed outdoor conditions and were used 

far past their service life.

33. During the grandfathering approval process, the Federal Railroad Administration failed to 

consider the limited useful service life of the polyester straps used for the Talgo Series VI 

trainset rolling assembly retention modifications which had degraded and failed to improve 

the crashworthiness of the train.

34. The Talgo Series VI trainset is structurally vulnerable if it is involved in a high-energy 

derailment or collision due to its lack of crashworthiness protections and is at risk to severe 

and catastrophic loss of survivable space.

35. The Talgo Series VI trainset designated as Amtrak train 501 was not in compliance with 

the terms and conditions of the Federal Railroad Administration’s grandfathering 

agreement.

36. Allowing the grandfathering provision to remain in Title 49 Code of Federal Regulations

238.203(d), “Grandfathering of noncompliant equipment for use on a specified rail line or 

lines,” is an unnecessary risk that is not in the public interest nor consistent with railroad 

safety.
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37. The Talgo Series VI trainset does not meet current United States safety standards and poses 

unnecessary risk to railroad passenger safety when involved in a derailment or collision.

38. The lead locomotive’s crashworthiness design and crash energy management features 

minimized the severity for injuries and fatalities to the train crew by performing as intended 

in this accident.

39. After the Talgo trainset separated from the power cars, there was no power to the train for 

emergency lighting which hampered the ability of passengers to evacuate the train and the 

ability of the first responders to conduct rescue operations within the railcar.

40. The lack of emergency lighting hampered the ability of passengers to evacuate the train 

and the ability of the first responders to conduct rescue operations within the railcar.

41. The instructional signs located above the railcar door exit controls and manual release 

mechanisms lacked the required high performance photoluminescent material or suitable 

alternative that would have allowed them to be visible and read in low-light or no-light 

environments.

42. The inability of the passengers to see and read the instructional signs regarding the exit 

controls and manual release mechanisms resulted in the inability of the passengers to use 

that point of egress for escape and delayed their evacuation from the train.

43. The rotation of the train seats (1) minimized the effectiveness of compartmentalization by 

allowing passengers to travel greater distances within the railcar during the accident, (2) 

caused injury to several passengers, (3) decreased the available aisleway space for 

passenger egress.

44. Existing procedures and design standards for antirotational seat locking mechanisms do 

not adequately protect passengers in accidents.

45. The failure of the articulated connections defeated the compartmentalization feature of 

AMTK 7421 (11) and provided a pathway for passenger ejection.

46. When the articulated connections failed, it resulted in a secondary collision that caused 

railcar AMTK 7424 (8) to roll over onto its roof and collapse its structure which dislodged 

the windows and allowed passengers to be ejected.

47. Limited research has been conducted into the effectiveness of compartmentalization in 

passenger railcars for individuals that fall outside of the testing standard range, such as 

small children.

48. The inability to secure child safety seats in a passenger train results in an undue risk to 

children due to uncontrolled or unexpected movements during a derailment or collision.

49. Amtrak should develop a policy for safely accommodating parents traveling with small 

children restrained in child safety seats.
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50. This accident shows the need for the Federal Railroad Administration to take action on 

Safety Recommendations R-16-35 and -36, which addressed the Federal Railroad 

Administration’s occupant protection standards.

51. Since there was no common incident command radio channel between fire and rescue 

agencies, law enforcement, and emergency management, the emergency response lacked 

efficient coordination.

52. The lack of interoperability of the emergency communications system used by Joint Base 

Lewis-McCord resulted in poor communications that adversely affected the coordinated 

rescue effort.

53. Incompatible radio frequencies or similar communication issues may exist at other 

locations where military and civilian agencies coordinate their emergency response.

3.2 Probable Cause

The National Transportation Safety Board determines that the probable cause of the 

Amtrak 501 derailment was Central Puget Sound Regional Transit Authority’s failure to provide 

an effective mitigation for the hazardous curve without positive train control in place, which 

allowed the Amtrak engineer to enter the 30-mph curve at too high of a speed due to his inadequate 

training on the territory and inadequate training on the newer equipment. Contributing to the 

accident was the Washington State Department of Transportation’s decision to start revenue 

service without being assured that safety certification and verification had been completed to the 

level determined in the preliminary hazard assessment. Contributing to the severity of the accident 

was the Federal Railroad Administration’s decision to permit railcars that did not meet regulatory 

strength requirements to be used in revenue passenger service, resulting in (1) the loss of survivab le 

space and (2) the failed articulated railcar-to-railcar connections that enabled secondary collisio ns 

with the surrounding environment causing severe damage to railcar-body structures which then 

failed to provide occupant protection resulting in passenger ejections, injuries, and fatalities.
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4.Recommendations

4.1 New Recommendations

As a result of this investigation, the National Transportation Safety Board makes the 

following recommendations:

To the Secretary of Transportation:

Require the Federal Railroad Administration to issue regulations for inward-facing 

recorders that include image and audio recordings as recommended by the National 

Transportation Safety Board in R-10-01 and R-10-02. (R-19-007)

To the Federal Railroad Administration:

Study the efficacy of how signs used in other modes of transportation may be 

effectively used in the railroad industry. (R-19-008)

Require railroads to periodically review and update their speed limit action plans 

to reflect any operational or territorial operating changes requiring additional safety 

mitigations and to continually monitor the effectiveness of their speed limit action 

plan mitigations. (R-19-009)

Require railroads to apply their existing speed limit action plan criteria for 

overspeed risk mitigation to all current and future projects in the planning, design, 

and construction phases, including projects where operations are provided under 

contract. (R-19-010)

Prohibit the operation of passenger trains on new, refurbished, or updated territories 

unless positive train control is implemented. (R-19-011)

Remove the grandfathering provision within Title 49 Code of Federal 

Regulations 338.206(d) and require all railcars comply with the applicable current 

safety standards. (R-19-012)

Use your authority and compel all commuter and passenger railroads to meet the 

requirements outlined in Title 49 Code of Federal Regulations Part 238 without 

delay, such that in the event of a loss of power, adequate emergency lighting is 

available to allow passengers, crewmembers, and first responders to see and orient 

themselves, identify obstacles, safely move throughout the railcar, and evacuate 

safely. (R-19-013)

Reevaluate existing seat securement mechanisms and their susceptibility to 

inadvertent rotation, to identify a means to prevent the failure of these devices to 

maintain seat securement. (R-19-014)
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Conduct research into the effectiveness of occupant protection through 

compartmentalization for passengers whose size (including children) is not within 

the current range of anthropomorphic passenger sizes in Federal Railroad 

Administration standards. (R-19-015)

To the United States Department of Defense Fire and Emergency Services Working Group:

(1) Identify all military installations that provide emergency services to areas 

outside of their installations, make them aware of this accident, and determine the 

effectiveness of the communications system between that military installation and 

the adjacent jurisdictions. (2) Implement a plan to address any deficiencies with 

interoperability caused by the incompatibility between the US Department of 

Defense communications system and that of adjacent civilian agencies. (R-19-016)

To the Washington State Department of Transportation:

Discontinue the use of the Talgo Series VI trainsets as soon as possible and replace 

them with passenger railroad equipment that meet all current United States safety 

requirements. (R-19-017)

To the Washington State Department of Transportation, Amtrak, and the Oregon 

Department of Transportation:

Develop and implement a program by which all railcar seats that are designed to 

rotate be checked for proper positioning and securement in place before the railcar 

can be placed into or returned to passenger carrying service. (R-19-018)

To the National Railroad Passenger Corporation (Amtrak):

Ensure operating crewmembers demonstrate their proficiency on the physical 

characteristics of a territory by using all resources available to them, includ ing:

in-cab instruments, signage, signals, and landmarks; under daylight and nighttime 

conditions; and during observation rides, throttle time, and written examinatio ns.

(R-19-019)

Revise your classroom and road training program to ensure that operating crews 

fully understand all locomotive operating characteristics, alarms, and the 

appropriate response to abnormal conditions. (R-19-020)

Require that all engineers undergo simulator training before operating new or 

unfamiliar equipment (at a minimum, experience and respond properly to all 

alarms), and when possible, undergo simulator training before operating in revenue 

service in a new territory and experience normal and abnormal conditions on that 

territory. (R-19-021)

Implement a formal, systematic approach to developing training and qualificatio n 

programs to identify the most effective strategies for preparing crewmembers to 

safely operate new equipment on new territories. (R-19-022)
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Work with host railroads and states that own infrastructure over which you operate

to conduct a comprehensive assessment of the territories to ensure that necessary 

wayside signs and plaques are identified, highly conspicuous, and strategically 

located to provide operating crews the information needed to safely operate their 

trains. (R-19-023)

Conduct training that specifies and reinforces how each crewmember, includ ing 

those who have not received their certifications or qualifications, may be used as 

a resource to assist in establishing and maintaining safe train operations.

(R-19-024)

Update your safety review process to ensure that all operating documents are up 

to date and accurate before initiating new or revised revenue operations.

(R-19-025)

Incorporate all prerevenue service planning, construction, and route verificatio n 

work into the scope of your corporate-wide system safety plan, including your rules 

and policies, risk assessment analyses, safety assurances, and safety promotions.

(R-19-026)

Work collaboratively with all host railroads and states that own infrastructure over 

which you operate in an effort to develop a comprehensive safety management 

system program that meets or exceeds the pending Federal Railroad 

Administration regulation, Title 49 Code of Federal Regulations Part 270, 

“System Safety Program.” (R-19-027)

Conduct risk assessments on all new or upgraded services that occur on 

Amtrak-owned territory, host railroads, or in states that own infrastructure over 

which you operate. (R-19-028)

Develop policies for the safe use of child safety seats to prevent uncontrolled or 

unexpected movements in passenger trains and provide customers with guidance 

for securing these child safety seats. (R-19-029)

To Central Puget Sound Regional Transit Authority:

Immediately conduct a review of all operating documents and ensure that safety 

mitigations are applied with uniformity throughout the entirety of your territory.

(R-19-030)

In areas of your territory where you are a host of a tenant railroad, coordinate with 

all current and any prospective tenants on the development of operating documents 

including timetables, general orders, and special instructions. (R-19-031)

Review your internal process for safety certification and verification, perform a gap 

analysis, and develop an action plan to address the deficiencies identified in the gap 

analysis and detailed in this report to enhance the verification activities on projects.

(R-19-032)
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4.2 Reiterated Recommendations

As a result of this investigation, the National Transportation Safety Board reiterates the 

following previously issued recommendations:

To the Federal Railroad Administration:

1. Enact Title 49 Code of Federal Regulations Part 270, “System Safety 

Program,” without further delay. (R-17-17)

2. Require railroads to install devices and develop procedures that will help 

crewmembers identify their current location and display their upcoming 

route in territories where positive train control will not be implemented. 

(R-16-32)

3. Conduct research to evaluate the causes of passenger injuries in passenger 

railcar derailments and overturns and evaluate potential methods for 

mitigating those injuries, such as installing seat belts in railcars and securing 

potential projectiles. (R-16-35) 

4. When the research specified in Safety Recommendation R-16-35 identifies 

safety improvements, use the findings to develop occupant protection 

standards for passenger railcars that will mitigate passenger injuries likely 

to occur during derailments and overturns. (R-16-36)
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4.3 Classified Recommendations

To the Federal Railroad Administration:

1. Require railroads to install devices and develop procedures that will help 

crewmembers identify their current location and display their upcoming 

route in territories where positive train control will not be implemented 

(R-16-32)

Safety Recommendation R-16-32 is classified Open⸻Unacceptable Response.

2. Conduct research to evaluate the causes of passenger injuries in passenger 

railcar derailments and overturns and evaluate potential methods for

mitigating those injuries, such as installing seat belts in railcars and securing 

potential projectiles. (R-16-35)

Safety Recommendation R-16-35 is classified Open⸻Unacceptable Response.

3. When the research specified in Safety Recommendation R-16-35 identifies 

safety improvements, use the findings to develop occupant protection 

standards for passenger railcars that will mitigate passenger injuries likely 

to occur during derailments and overturns. (R-16-36)

Safety Recommendation R-16-36 is classified Open⸻Unacceptable Response.

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

ROBERT L. SUMWALT, III EARL F. WEENER

Chairman Member

BRUCE LANDSBERG JENNIFER HOMENDY

Vice Chairman Member

Report Date: May 21, 2019
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Board Member Statements

Vice Chairman Bruce Landsberg filed the following concurring statement on June 3, 2019.

I concur with the report and its findings, probable cause, and recommendations, and 

I would like to add some additional comments.

There was a Titanic-like complacency and certainty exhibited by those tasked with the 

safety, operation and management of the Point Defiance Bypass rail line before the revenue service 

started in 2017. Like the Titanic, the crash happened on the very first passenger run. The term 

“accident” is inappropriate because that implies that this was an unforeseen and unpredictab le 

event. It was anything but unforeseeable. The NTSB has been investigating overspeed derailments 

around curves for decades. Likewise, NTSB has made recommendations to the Federal Railroad 

Administration (FRA) and to the railroads to implement Positive Train Control (PTC) for decades. 

The NTSB, like all accident investigation organizations, operates with the benefit of 

hindsight. It’s always easier to judge after the fact. I myself have engaged in Monday Morning 

Quarterbacking on occasion. But to continue the football metaphor, when a team keeps losing 

games for the same reasons and the coaches and players are not studying the game tapes, it’s time 

for some soul searching.

The engineer’s failure was the final link in a very long chain of mismanagement events. 

The root cause was extremely lax safety oversight, unclear responsibility, and poor training. 

Railroad management and safety implementation were lacking at almost every level. Member 

Homendy noted that safety was the FRA’s primary function, not economics or political 

expediency. According to FRA’s own website:

The Federal Railroad Administration's (FRA) mission is to enable the safe, reliable, 

and efficient movement of people and goods for a strong America, now and in the 

future. FRA executes this mission through development and enforcement of safety 

regulations, investment in passenger and freight rail services and infrastructure, and 

research into and development of innovations and technology solutions.

There was plenty of financial oversight but not enough attention on safety and operational 

aspects. As Chairman Sumwalt noted, AMTRAK is now operating under new management since 

the crash and appears to be moving in a much more positive safety direction. They understand that 

the training provided to the train crews was insufficient. Crew Resource Management cannot work 

when there are two new-to-the-route crew members and the operator is unfamiliar with the 

locomotive.

Multiple agencies were involved but somehow missed critical factors. By Sound Transit’s 

own Safety and Security Management Plan (SSMP), the curve was deemed an unacceptable safety 

risk without implementation of PTC. Yet apparently, senior management signed off with no 

mitigations in place. Who’s accountable? 

The use of timetables, a procedure employed by traincrews dating well back into the last 

century, was thought to be sufficient. NTSB has seen that methodology fail consistently in 
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previous accidents. Why continue to rely on a system that requires such a high level of human 

performance?

Railroad signaling and signage works if everyone performs their jobs correctly – otherwise 

it fails periodically. NTSB has and is making recommendations to encourage the rail community 

to adopt far more conspicuous signage, as is used in other transportation modes to attract crew 

attention. Readily available technology to enhance situational awareness currently exists. The 

science of conspicuity and alerting in human factors is well known. It’s time to adopt it. 

NTSB Recommendation R-16-32 to FRA was issued in 2016 after a previous curve 

overspeed crash: “Require railroads to install devices and develop procedures that will help 

crewmembers identify their current location and display their upcoming route in territories where 

PTC will not be implemented.” 

The FRA and many of its constituent railroads assert that the technology does not currently 

exist and has little to no known safety benefit to offset its significant cost. They believe that a 

regulation requiring railroads to install such technology would be redundant with existing rules. 

NTSB has kept this recommendation open and categorized the response as “unacceptable. ” 

My hope is that FRA and the railroads just misunderstood the recommendation, and I must assume 

that none of their management or staff have any familiarity with map applications on smart phones 

and tablets. Moving maps as supplemental equipment on tablets and installed devices have been 

used for a decade or more in aircraft, boats and other ground transport vehicles. That’s how 

navigation is done today. GPS is provided by the taxpayers to all and a simple dedicated 

application for rail use would not cost “hundreds of millions of dollars,” as stated by FRA.

AMTRAK is currently testing such an app while FRA and other railroads refer to existing 

regulations that require locomotive engineers and conductors be familiar with the characteristics 

of the territory in which they will be working. Time to review the game tapes – again.

Would it be perfect? No! Would it meet the standard for current railroad signaling? No! 

It’s intended to be supplemental to all the existing systems that should prevent accidents all the 

time but quite clearly fail periodically. This is not a replacement or substitute for PTC, but it should 

improve the situational awareness of crews significantly. Test it!

Finally, it’s way past time for Congress to stop granting exemptions and exceptions to a 

law that was passed in 2008 requiring full implementation of PTC on passenger routes by 2015. 

It’s also way past time for many railroads and their regulatory authorities to take their management 

and safety oversight responsibility seriously.
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Member Jennifer Homendy filed the following concurring statement on May 31, 2019.

Chairman Robert L. Sumwalt, III, Vice Chairman Bruce Landsberg, and Member Earl F. 

Weener joined in this statement.

I concur with the report and its findings, probable cause, and recommendations, and 

I would like to add some additional comments.

In 2009, the Federal Railroad Administration (FRA) issued its final decision to approve 

Amtrak’s petition to exempt the Talgo VI trainsets from passenger railcar crashworthiness 

standards. This exemption allowed the trainsets to continue operating on BNSF tracks near Point 

Defiance and along the southern Puget Sound. At the time, there was tremendous excitement 

among federal, state, and local entities and Amtrak about new opportunities to develop high-speed 

rail and upgrade existing routes, as Congress had just provided the largest infusion of capital in 

passenger rail in decades.

Each of the entities involved with the petition – Amtrak, Sound Transit, the Washingto n 

State Department of Transportation, and the FRA – were laser focused on moving forward projects 

that would reduce travel time, boost ridership, and provide an alternative to increasingly congested 

highways, but within those discussions safety seemingly became less of a priority. In fact, during 

a public hearing on the petition, the FRA argued against concerns raised by some commenters 

about the safety of the trainsets, stating that the FRA’s role was not to determine whether the 

proposed exemption provided “an equivalent level of safety” to the more stringent passenger 

railcar crashworthiness standards, but to determine whether the exemption was “consistent with 

railroad safety,” as if there are varying levels of safety.

While 49 Code of Federal Regulations 238.203 did, in fact, require the FRA to determine 

whether the petition was in the public interest and consistent with railroad safety, the FRA 

neglected its core mission, mandated by Congress in the Rail Safety Improvement Act of 2008 

(RSIA) (Public Law 110-432, Division A), which states: “In carrying out its duties, the 

Administration shall consider the assignment and maintenance of safety as its highest 

priority...”.62

While the law lays out additional duties, such as developing high-speed rail, it is safety that 

is required to be the FRA’s highest priority, not the efficient movement of people or goods.

NTSB investigators did a tremendous job of identifying a number of deficiencies in FRA’s 

evaluation and approval of Amtrak’s petition for exemption in 2009 on the Puget Sound route. 

Those deficiencies included FRA’s failure to require more comprehensive safety analyses and 

more stringent risk mitigations, such as positive train control, and its approval of Amtrak’s second 

petition for exemption in 2017, just four days before the accident, to allow operations on the Point 

Defiance Bypass, with no safety documentation whatsoever.63

 62 49 United States Code 103. 63 49 Code of Federal Regulations 238.203(h)(2) authorizes the FRA to attach special conditions to the approval of 

petitions for exemption to passenger railcar crashworthiness standards. Analyses by Arthur D. Little, a contractor for 
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I could continue at length about each of these but there is one issue the team raised that 

should be highlighted: lack of a safety management system (SMS) program at Amtrak. The NTSB 

has long recommended the implementation of SMS across all modes of transportation. Although 

not required (it should be), SMS is becoming a standard of practice among Part 121 (commercial 

aviation) operators. There are four components to SMS per Federal Aviation Administratio n 

Order: 

• a safety policy that sets out what the organization is trying to achieve; outlines the 

requirements, methods, and processes the organization will use to achieve the desired 

safety outcomes; establishes senior leadership’s commitment to incorporate and 

continually improve safety in all aspects of the business; and reflects management’s 

commitment to implementing processes and procedures for establishing and meeting 

safety objectives and promoting a safety culture

• a safety risk management process that identifies all hazards, analyzes the risk, assesses 

the risk, controls the risk, and then continually evaluates whether those risk 

management strategies are working

• a safety assurance process that evaluates the continued effectiveness of, and 

compliance with, requirements and implemented risk control strategies and supports 

the identification of new hazards

• a safety promotion program which includes training, communication, and other actions 

to create a positive safety culture within all levels of the workforce

I believe that had Amtrak developed and implemented a comprehensive SMS, this accident 

would likely never have occurred. 

This accident is not the first time we have raised the importance of Amtrak implementing 

SMS. In 2016, an Amtrak train traveling near Chester, Pennsylvania, struck a backhoe with a 

worker inside, killing the operator and a track supervisor and injuring 39 others. In our report, we 

recommended that Amtrak develop a comprehensive SMS that vitalizes safety goals and programs 

with executive management accountability; incorporates risk management controls for all 

operations affecting employees, contractors, and the traveling public; improves continually 

through safety data monitoring and feedback; and is promoted at all levels of the company. We 

issued a near identical recommendation in this report, and we reiterated our recommendation that 

FRA implement its “System Safety Program” rulemaking, without further delay.

The “System Safety Program” rulemaking was issued in response to section 103 of RSIA, 

which required the Secretary of Transportation to promulgate a regulation that requires each Class 

I railroad and railroad carriers that provide intercity rail passenger or commuter rail passenger 

transportation to develop and implement a railroad safety risk reduction program that 

 Amtrak, evaluated the benefits of PTC, which showed that implementation of PTC along the Pacific Northwest 

Corridor would reduce the risk of fatalities by 47 percent and the risk of injury by 30 percent.
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systematically evaluates railroad safety risks on its system and manages those risks in order to 

reduce the numbers and rates of railroad accidents, incidents, injuries, and fatalities. 

RSIA was enacted in 2008; the FRA issued its final rule to address section 103 in 2016, 

but the Department of Transportation has delayed its implementation six times. The final rule is 

now set to go into effect in September 2019. I hope that the FRA holds to this new date, but if it 

does not, the railroads, including Amtrak, cannot and should not wait on the FRA to take action. 

It is each railroad’s responsibility to ensure the safety of their employees and their riders in all 

aspects of their business operations.
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Appendixes

Appendix A. Investigation

The National Transportation Safety Board (NTSB) was notified on December 18, 2017, of 

the accident in which a Cascades Service Amtrak passenger train had derailed onto Interstate 5. 

Initially, there were an unknown number of fatalities, but a confirmation of multiple passengers 

injured. The NTSB launched Board Member Bella Dinh-Zarr, who was the on-scene spokesperson, 

and a team to investigate track, signals and train control, railroad operations, mechanical, 

crashworthiness, survival factors, event/data/video recorders, human performance, medical issues, 

and an investigator-in-charge.

The NTSB Transportation Disaster Assistance Division was also on scene to provide 

assistance with victims and victims’ families.

The parties to the investigation include Federal Railroad Administration, Washingto n 

Utilities and Transportation Commission, Amtrak, Central Puget Sound Regional Transit 

Authority, Washington State Department of Transportation, Talgo, Inc., Siemens Industry, Inc. the 

Brotherhood of Locomotive Engineers and Trainmen; and the International Association of Sheet 

Metal, Air, Rail and Transportation Workers.

On July 10-11, 2018, the NTSB held an investigative hearing, National Railroad Passenger 

Corporation (Amtrak) Operations on Host Railroads and Safety Management Systems-involved 

Accidents (DuPont, Washington, December 18, 2017, and Cayce, South Carolina, February 4, 

2018.
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Appendix B. DuPont Railroad of Record

Attached is a flowchart explaining the railroad of record for each component of the DuPont 

accident.

Figure 42. Railroad of record.
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