Trains – October 2019

HUMAN ERROR COMBINED WITH
inadequate attention to safety
led to the fatal crash of
Amtrak’s Silver Star into a CSX
Transportation train in Cayce,
S.C., on Feb. 4, 2018, the
National Transportation Safety
Board concluded at a meeting
in July.
The Amtrak train was di-
verted off the main line and
into a parked CSX auto-rack
train at more than 50 mph be-
cause of an improperly lined
switch. The Silver Star’s e n g i -
neer and conductor were killed
and 91 passengers were injured.
Investigators focused on the
failure of CSX to identify and
mitigate the risk of operating
trains under a signal suspen-

sion on a 23-mile segment of

the railroad’s Columbia Subdi-

vision. The signals were sus-

pended because CSX was in-

stalling positive train control,

the system intended to prevent

exactly the kind of accident

that occurred at Cayce, a few

miles south of Columbia, S.C.

The conductor of the local

freight reported to the engineer

that he had realigned a switch

to the main track, and the engi-

neer had informed the dis-

patcher that the switch was in

the correct position. It was not.

“CSX failed to ensure that

this crew was properly pre-

pared to perform the tasks

CSX assigned them to do that

night,” NTSB Chairman Robert

Sumwalt said.

The NTSB repeated a recom-

mendation that the Federal Rail-

road Administration issue an

emergency order requiring rail-

roads to operate at restricted

speed approaching switches

when a signal suspension is in

effect. The FRA only advised

railroads to do so late last year.

Amtrak decided to follow

the NTSB’s guidance, with a

“glaring lack of pushback” from

its host carriers, noted Richard

Hipskind, the lead investigator

in the Cayce crash.

The NTSB also repeated its

call for FRA to do more to pre-

vent crashes caused by mis-

aligned switches, such as re-

quiring the installation of

switch position indicators.

“I believe that the conduc-

tor had every intention of

following the rules and thought

that he did,” testified Mike

Hoepf, an NTSB human

performance investigator. “He

just made a mistake.”

Compounding that mistake:

a lack of attention by CSX to

the risk of putting a train crew

in an unfamiliar situation and

expecting them to perform at

the same level.

Investigators found CSX

never conducted efficiency test-

ing, or a skills assessment, on

the engineer or conductor of

train F777 to ensure proper

switch alignment.

The NTSB also cast doubt

NTSB cites human error, lax safety

planning in Silver Star wreck

Findings again take issue with Federal Railroad Administration actions

10 OCTOBER 2019

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