NTSB rules human error, safety oversights caused 2017 Amtrak derailment on I-5

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

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

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

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

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

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

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

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

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

One car was left dangling in the air.

Several panicked passengers called 911.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

He and the conductor had never worked together before.

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

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

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

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

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

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

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

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

NTSB rules human error, safety oversights caused 2017 Amtrak derailment on I-5