CA: Cause of light rail crash that injured two dozen Sacramento passengers detailed in NTSB report
Sacramento Regional Transit’s “weak administrative controls” were the likely cause of the light rail crash that injured more than two dozen people, federal investigators have concluded.
In its final report, the National Transportation Safety Board concluded that the collision between a two-car passenger train and a one-car maintenance train on August 22, 2019 occurred because RT senior management failed to “assessed the competency of a transportation supervisor in the combined role of evening shift controller and dispatcher.
The crash happened around 9:38 p.m. on a remote stretch of the Blue Line near the Hagginwood neighborhood of North Sacramento when an RT train with 24 occupants collided head-on at 32 mph with a stopped test train with three occupants .
No train derailed, but all 27 people suffered minor injuries; 13 were transported to hospitals. The transportation agency estimated the damage to be over $242,000.
“SacRT continues to express its deepest condolences to all of the individuals and families who were affected and is very grateful that there were no serious or fatal injuries as a result of this collision,” the agency said. in a statement Friday.
Investigators found that the RT transportation supervisor failed to follow procedures when he allowed the test train to enter the main track without knowing the location of the passenger train or alerting the train operator to passengers of the presence of the test train.
Clear warning signs or devices placed on the main track before the test train began its final run “would have alerted the passenger train operator to the tests in progress”, according to the report released last week.
Additionally, investigators said a transmission-based train control system “could have applied the passenger train’s brakes and stopped it before it collided with the test train”, one of many recommendations made by the NTSB in the report.
RT said it implemented several safety measures, such as requiring derailleurs and stop signs at each end of the track during testing. Transport supervisors must now issue a radio bulletin when test trains head to the main line, and all working train operators must recognize bulletins as radio replays.
“SacRT has gone above and beyond to focus on improving its security program,” the agency told The Sacramento Bee.
Supervisor had previous “competence” issues
The safety office did not name the transport supervisor on duty at the time of the accident. Investigators say he was hired in January 2018 and had worked for five years prior as a train dispatcher for Canadian Pacific Railway.
During the first supervisor performance evaluation, conducted eight months before the accident, a transportation superintendent had noted that “the supervisor’s radio control functions still need improvement.”
“Sometimes missing radio calls. Be more aware of activity on the line. Sometimes slow decision making. Sometimes no clear and concise instructions,” the superintendent wrote, according to federal investigators.
The supervisor did not make significant improvements and was eventually put on a 90-day performance improvement plan in April 2019. A senior RT employee supervised the supervisor’s work for a few weeks, but changed his mind. team in June 2019, ending surveillance.
“SacRT missed an opportunity to monitor how the transportation supervisor, who continued to develop and refine his skills, performed these combined job demands,” the investigators wrote. “By choosing to end his PIP and not continue to monitor the Transport Supervisor, SacRT had no reliable means of determining whether the Transport Supervisor was performing his duties to an acceptable level.”
The NTSB investigation does not indicate whether the supervisor was disciplined after the crash, and a statement from RT did not include any action against the supervisor.
One last test, and a failed radio procedure
In interviews with RT staff and a review of radio calls, investigators pieced together what led to the crash.
That night, an operator finishing maintenance on a test train wanted to test its propulsion system. The plan was to conduct a high-speed test on the main Blue Line track near Marconi/Arcade station – a common practice, according to investigators, which takes around 10 minutes.
Fifteen minutes before the crash, the test operator phoned RT’s Metro Control transportation supervisor to ask if he could perform the final test.
The operator told investigators that the supervisor cleared him to continue. The supervisor told the NTSB he instructed the test operator to wait for a passenger train to pass and then radio for formal clearance. There was no recording of the phone call and the test operator told the board that the passenger train was not discussed.
Protocol required the transport supervisor to issue a notice by radio to all trains on the mainline that a test train was arriving. The directives stated that a radio conversation should have taken place between the supervisor and the nearest passenger train operator – which the supervisor did not do.
The supervisor told investigators that “the operator of the test train called him, ‘ten things happening at once’, including a situation involving an unruly passenger on another revenue train”.
At 9:31 p.m. the test operator radioed for permission to enter the mainline. The two did not discuss the passenger train, according to the recorded radio call. A minute later, the test train entered the main line and headed north from the maintenance facility toward the Grand Avenue level crossing.
After performing the tests, the test train operator changed direction, heading south toward the maintenance facility, which is just south of Marconi/Arcade station.
It was then that he noticed a lighthouse about 400 meters ahead of him, partially obscured by trees and vegetation.
One minute before the accident, train 9 left Marconi/Arcade station with a “yellow signal”, allowing an operator to proceed with caution while remaining aware that the next signal could be red.
As Train 9 passed through Arcade Creek, its operator saw the signal to change several times. The operator slowed the train as he saw the signal change from yellow to red, yellow and red again, then back to yellow again, according to investigators.
When the train came out of a curve, the operator of train 9 saw the test train’s headlight but “but was unable to immediately determine” whether it was on the main line, have said investigators.
Traveling at 48mph and about 65m from the test train, the passenger train operator realized it was headed for a collision. At 9:38 p.m., he applied the emergency brakes, activated the deadman’s switch, and braced for impact.
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