The National Transportation Safety Board seized on the April 2016 crash in Chester, Pennsylvania, as the tragic outcome of years of rule bending, corner cutting and punitive policies that had endangered and upset Amtrak workers and their unions.
Lapses in communication and a lack of required equipment left the Chester workers with no protection and little warning as the Savannah, Georgia-bound Palmetto train streaked toward their backhoe at more than 100 mph.
A foreman who had just taken charge of the maintenance crew did not ask a dispatcher to keep routing trains away from the workers, investigators said, nor did he have a device meant to prevent trains from running on the same tracks as workers, even though Amtrak rules require its use.
In all, investigators flagged more than two dozen safety issues in the crash, far more than in most crash investigations, according to NTSB board member Earl Weener. Backhoe operator Joseph Carter Jr., 61, and supervisor Peter Adamovich, 59, were killed and about 40 passengers were injured.
"Had any of these issues been addressed, the accident may have been prevented," NTSB investigator Joe Gordon said at a public meeting on the crash at the agency's Washington headquarters.
Workers told investigators that they felt Amtrak had been emphasizing on-time performance over safety, belying the big, red "think safety" signs it posted in employee lounges and its threats to fire workers who broke certain rules.
NTSB chairman Robert Sumwalt said Amtrak's grab bag of priorities created a culture of fear and non-compliance that encouraged workarounds to "get the job done." Amtrak's unions, wary of its approach, refused to participate in two of the railroad's safety programs, Sumwalt said.
Amtrak's co-chief executive officers, Richard Anderson and Charles "Wick" Moorman sent a letter to employees Tuesday updating them on steps the railroad has taken to transform its safety culture since the crash.
They include hiring a new head of safety, compliance and training, issuing alerts and advisories to remind workers of rules and an improved worker-protection training program.
"Our customers expect us to operate safely and our jobs and lives depend on it," the co-CEOs wrote. "We can and will do better. Our pledge to you is that we will do everything possible to help move us forward."
Carter's family is suing Amtrak for negligence. Their lawyer, Tom Kline, said they can only hope his death "will result in wholesale changes" in safety at Amtrak.
Toxicology reports showed that Carter had cocaine in his system, Adamovich tested positive for morphine, codeine and oxycodone and the train's engineer, Alexander Hunter, 47, tested positive for marijuana.
Only Hunter, as a train crew member, would have been subject to random drug testing at the time of the crash. He is no longer employed by Amtrak. No amount of marijuana use by an engineer is acceptable, the railroad has said.
In June, federal regulators expanded the testing program to include track maintenance workers. On Monday, the Federal Railroad Administration issued a rule mandating testing for opioids beginning Jan. 1.
The union representing maintenance workers said drugs played no role in the severity or cause of the crash. The NTSB said the positive tests were another indication that Amtrak's safety culture had eroded to the point where workers were not deterred from using drugs.
Hunter told investigators that he knew of maintenance work being done in the area but was not given any warnings about equipment being on the same track as his train.
Hunter blew the train's horn and hit the brakes once he saw equipment on an adjacent track and then on his own track. Investigators say that was about 12 seconds before impact.
The train slowed from 106 mph to 100 mph at impact and only came to a complete stop about a mile down the track. The lead engine of the train derailed.
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