NTSB: Fatal Amtrak derailment shows need for more track inspections

July 31, 2023

“Poor track conditions” of a track owned by BNSF may have contributed to a fatal September 2021 accident involving an Amtrak train derailment in Joplin, Montana, according to the National Transportation Safety Board.

But NTSB’s investigation report also points to wider questions on how the freight rail industry should deploy technological tools such as autonomous track monitoring systems and what role visual inspections by a human inspector might play in inspections. The federal agency is recommending that the Class I railroads increase both types of inspections.

NTSB, which recently issued its final report on the derailment, determined that the Sept. 25, 2021, derailment of Amtrak’s westbound Empire Builder may have been caused by worn rail, vertical track deflection, subgrade instability and track misalignment. The derailment of the train, which consisted of two locomotives and 10 cars, occurred while it was on a right-hand curve. Three passengers died and 49 passengers and crew were injured.

“This tragedy is a powerful reminder that there’s no substitute for robust track inspection practices, which can prevent derailments by identifying track conditions that may deteriorate over time,” NTSB Chair Jennifer Homendy said in a Thursday release. “I implore track owners, who are responsible for the safety of their routes, to ensure inspectors have the time, support, and resources needed to do their work, which is essential to rail safety.”

In response to NTSB’s report, BNSF (NYSE: BRK-B) said it is “committed to safety across our system.” The western U.S. rail carrier is also still reviewing NTSB’s filings.

“BNSF regularly inspects all aspects of our network, including our locomotives, track, rail and bridges, and we conduct additional weather-event inspections as conditions demand,” BNSF told FreightWaves in a Friday statement. “Our team of trained inspectors deploys advanced equipment including instrument-equipped rail cars, bridge inspection vehicles and unmanned aerial vehicles (UAVs). BNSF inspections meet all federal requirements, and we are committed to timely maintenance, repair and replacement whenever issues or potential issues are detected.”

In NTSB’s announcement of the final report, the federal agency noted a need for regulations for rail wear limits requiring the replacement of worn rail. NTSB also said walking inspections are important because they ensure an understanding of track conditions. In addition, NTSB was critical of BNSF’s “shortcoming in its safety culture” because of the way it has handled the workload management of safety employees, including potentially overwhelming the track inspector’s workload and preventing the inspector from performing a timely walking inspection.

NTSB’s report refers to one inspector for the track in question, although it doesn’t specify how many inspectors would be or should be involved in overseeing that part of the network.

“The most likely reason that the track inspector did not perform a walking inspection of the derailment curve in about a year is that he did not have time. In comparison to hi-rail inspections, walking inspections are time intensive and the track inspector was already pushing the limit of hours that could be physically worked in a week just to meet the FRA minimum inspection requirements for the hundreds of track miles he was responsible for inspecting,” NTSB said in its final report. “Thus, the NTSB concludes that the track inspector likely could not perform a required walking inspection of the derailment curve due to his assigned workload to inspect an excessive amount of track.”

NTSB also noted that some of the windows of the Amtrak car failed to stay in place when the car rolled over, which contributed to the severity of injuries, and the compartmentalization of Amtrak’s passenger cars may not have protected passengers adequately during the derailment.

The investigation led NTSB to issue a number of new safety recommendations: three to the Federal Railroad Administration, two to BNSF and one to all Class I and intercity railroads. The recommendations note the limitations of track inspection practices and of autonomous monitoring systems, and they address the treatment of installed rails and track.

NTSB’s safety recommendations to FRA include regulations setting limits for rail head wear, and they address rail joints. NTSB also called for a process that would automatically trigger a slow order if a railway receives certain alerts from track inspection devices.

NTSB recommended that BNSF complete a thorough evaluation of the track curve involved in the derailment and make repairs.

NTSB urges more frequent autonomous track inspections

While NTSB determined that the expanded use of autonomous track inspection to detect track geometry conditions could reduce the likelihood of train derailments, the federal agency also said these inspections should not replace or supplant the inspector.

“All methods of track inspection are necessary and provide actionable information to inspectors in different circumstances—one mode of inspection should not be considered superior to another mode for all track inspection needs,” NTSB said in its report.” For example, automated track inspections by geometry cars or railcar-attached devices provide detailed information on specific track parameters, but they do not capture the diverse array of unique track hazards detectable to human inspectors. They are intended to supplement an inspection program and should not be used to supplant an inspector physically examining a track.”

Rather, railways such as BNSF should increase the frequency of autonomous track inspections since a more frequent inspection may have detected the issues with the track involved in the derailment.

FRA should “establish interoperability requirements among railroads to implement a process in which a predetermined critical alert from a [vehicle/track interaction (V/TI) onboard component monitoring system] would require an immediate slow order that remains in place until a walking inspection is performed and, if needed, subsequent repairs are completed,” NTSB said in its final report.

The agency also said “the expanded use of V/TI monitoring systems across Class I and intercity railroads to detect track geometry conditions earlier could reduce the likelihood of train derailments. Therefore, the NTSB recommends that all Class I and intercity railroads with trains operating on main tracks equip all trains with an autonomous monitoring system, such as V/TI, to detect track geometry defects.”

In response, BNSF said it has been steadily deploying technological tools, such as trackside detectors and VTI technology.

“BNSF deploys more than 4,000 trackside detectors that collect and disseminate data around the clock to help us optimize the safety and reliability of our network and equipment. Wayside detectors, driven by artificial intelligence, produce vast amounts of data sets analyzed by computers to evaluate the health of passing trains, identifying conditions otherwise undetectable to the human eye. Detectors are equipped with thermal, acoustic, visual and force sensors that alert us to potentially dangerous conditions, enabling BNSF to stop trains until the conditions are addressed and any safety issues are resolved,” BNSF told FreightWaves.

The railway continued, “Even before this report was released, BNSF had begun installing Vehicle Track Inspection (VTI) technology on locomotives and had been proactively implementing Automated Track Inspection (ATI), which analyzes geometry testing and visual inspection data and applies a score along with other factors. This score produces a visual inspection frequency which may require BNSF track inspectors to inspect the track more frequently than minimum FRA requirements.”

BNSF also said it has standards for rail replacement based on size of rail and on wear limits, and it has replacement criteria based on defect rates.

“These limits are constantly evaluated and are programmed into BNSF’s capital plan. In fact, this year, BNSF will replace 346 miles of rail and approximately 2.8 million rail ties,” BNSF said.

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