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After derailment, NTSB blames the engineer, not Amtrak

This week I learned that railroad barons still have power: they have successfully resisted safety measures that have for decades been standard for airlines and other transportation. I also learned that, by focusing on the wrong questions, federal safety agencies help keep railroads unsafe.

After a year of careful study, the National Transportation Safety Board announced that the likely cause of the Amtrak 188 derailment in May 2015 that killed eight people and injured over 100 more was the engineer. The Board noted repeatedly that, had Amtrak turned on a safety system it had already installed, there would have been no accident at all. Nonetheless, the NTSB just couldn’t bring itself to blame Amtrak – even though the railroad has itself already admitted legal liability and agreed to pay compensation for damages. The NTSB spent most of its meeting talking about the engineer, Brandon Bostian, saying that he’d lost track of where he was and was speeding up when he should have been slowing down. They noted that Bostian hadn’t been drinking or talking on his cell, hadn’t been sleep deprived, hadn’t taken drugs and had a record of good behavior. They concluded that he was likely distracted by listening to radio reports about another train incident nearby. Faced with the fact that he’d made a mistake, but hadn’t done anything obviously wrong, they nonetheless continued to focus on him. They ended up recommending new training courses for engineers in multitasking (even though there’s plenty of evidence that such courses are ineffective).

If lack of attention can be a “cause,” why can’t lack of safety systems? The NTSB and staff repeatedly noted that Amtrak hadn’t turned on its positive train control (PTC) safety system — which was already set up, but not required to be turned on until the end of the year — and that, had Amtrak done so, there wouldn’t have been an accident at all.

They also noted that NTSB had recommended adoption of PTC safety systems for over 45 years. Nonetheless, NTSB shied away from saying that the lack of proper safety systems caused the accident. When one of the board members recommended listing both lack of a functioning PTC and engineer distraction as primary causes, the staff and the three other board members opposed the idea. The staff said, in effect, “Amtrak is doing more than other carriers, so we don’t want to criticize them”— even though it wouldn’t have been hard to have turned on the system immediately, rather than waiting until it was required at year-end.

It’s worth noting that NTSB has traditionally focused on human error rather than safety systems. For example, when the plane’s electrical system failed and members of the Oklahoma State University basketball team died in a 2001 crash, the NTSB said the cause was pilot error, that he could still have flown the plane using other instruments. Fortunately, the Federal Aviation Administration recognizes the shortcomings of human pilots and requires multiple backup safety systems. Unfortunately, the Federal Railroad Administration does not; it repeatedly failed to require PTC. Dozens have died in fatal rail accidents as a result, 37 since 2008 on Amtrak alone.

Since the purpose of the NTSB is to improve safety, one must wonder whether downplaying the failures of organizations to implement safe systems and focusing overwhelmingly on the poor engineer isn’t a missed safety opportunity. At a minimum, it was a missed educational opportunity, since virtually all the news reports headlined the engineer and buried the lack of safety systems in the text, if they mentioned it at all.

Former NTSB member Kathryn (Kitty) Higgins agrees. She said, “We put a man on the moon in far less time than it has taken to make progress on PTC. … It is outrageous and inexcusable that this technology hasn’t been and won’t be installed by the original congressional deadline. At a time when the auto industry is moving ahead with smart cars, driverless cars and other advanced technology to advance safety, it is ridiculous that we don’t have smart trains and rail systems.”

NTSB is an exceedingly knowledgeable and professional agency. Both the board and staff clearly care about safety and safety systems, but after 45 years maybe they’d be more successful if they started recognizing that the lack of such systems kills, too.

Editor’s note: This piece originally appeared in Roll Call.

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