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NTSB Blames Chester Train Crash on Weak Safety Culture

Chester Train Crash

The National Transportation Safety Board (NTSB) has issued its final report into the deadly 2016 train crash in Chester, Pennsylvania, which killed two people and injured 39. In its report, the NTSB blasts Amtrak for multiple safety issues. The agency also found the Federal Railroad Administration failed to require safety signals that could have prevented the accident. As a result of its investigation, the NTSB made 14 safety recommendations, including nine directed at Amtrak. The crash highlighted the importance of strong railroad safety oversight.

Two Killed in 2016 Amtrak Train Crash

On April 3, 2016, at around 7:50 a.m., Amtrak train 89, pulling eight passenger cars, a baggage car and a café car, was headed from New York City to Savannah, Georgia. On board were seven crew members and 337 passengers. As the train made its way through Chester, it wound up on tracks that should have been closed for maintenance and collided with a backhoe, killing the two maintenance workers on the tracks. Around 40 people on the train suffered injuries in the collision and resulting derailment.

Among the issues that the NTSB revealed when it released its documents regarding the crash were that at least three workers tested positive for drugs:

  • Joe Carter, the backhoe operator who died in the collision, tested positive for cocaine;
  • Peter Adamovich, Carter’s supervisor who also died in the crash, tested positive for codeine, oxycodone and morphine despite not reporting medication use; and
  • Alex Hunter, train 89’s engineer, tested positive for marijuana.

Confusion Regarding Out-of-Service Tracks Led to Train Collision

Just after 7:00 a.m. the morning of the crash, the night foreman ended his shift with three tracks—one, three and four—out-of-service. The day foreman confirmed he would need the three tracks out of service for maintenance work. Just before 7:30 a.m., however, a different supervisor called dispatch and allowed the three tracks to be put back in service. The supervisor made that call via cell phone, not over the radio, so the day foreman did not know the tracks were put back in service.

As a result, the track the backhoe was on was cleared for service, allowing train 89 to travel on it. The engineer had only 16 seconds to respond to the backhoe on the tracks and managed to slow the train from 107 miles per hour to 99 miles per hour, but the force of the collision was still far too great, and the two workers on the tracks were killed.

NTSB Blames Pennsylvania Train Crash on “Fractured Safety Program”

Although drug use by the Amtrak engineer and workers was not found to be a factor in the Chester train crash, the NTSB said the drugs in the workers’ systems were “symptomatic of a weak safety culture at Amtrak.” The board further noted that Amtrak did not ensure its employees were drug-free while performing their duties.

Amtrak’s safety culture is failing, and is primed to fail again, until and unless Amtrak changes the way it practices safety management,” said NTSB Chairman Robert L. Sumwalt. “Investigators found a labor-management relationship so adversarial that safety programs became contentious at the bargaining table, with the unions ultimately refusing to participate.”

The NTSB blamed the crash on “deficient safety management across many levels of Amtrak and the resultant lack of a clear, consistent and accepted vision for safety.”

Perhaps most vital to this was the “widespread acceptance at Amtrak of not using supplemental shunting devices,” which ensure the dispatcher knows which tracks are occupied by workers, potentially preventing a disaster. Even though Amtrak required supplemental shunting devices, the foreman had none to apply. The NTSB further found the supervisor did not conduct a thorough job briefing and Amtrak did not have a detailed work plan to ensure worker safety.

Finally, although the train was traveling at less than the 110 miles per hour speed limit through the zone, the NTSB notes that Amtrak should have required trains moving through the area to travel at a significantly lower speed, which could have decreased the accident’s severity.

Despite the emphasis on rules compliance, investigators did not find a culture of compliance,” Sumwalt said. “Rather, they found a culture of fear on one hand and a normalization of deviance from rules on another hand.”

Amtrak Failure of Protocol is the Immediate Cause of the Chester Train Crash

Although the NTSB made the point that personal cell phones should not be used for important communications, it does not stress that it appears the railroad had no protocol in place requiring important communications be made over the system radio rather than by private cell phone call. Had the supervisor who made the cell phone call putting the track under maintenance back into service been required to review the situation with the outgoing supervisor, and to make the call over the radio so that the workers on site knew what he was doing, this tragedy never would have occurred.

The emphasis on drug policy, while important, is misplaced in this situation: no worker with drugs in his system contributed to this disaster. Failure of management, at the policy and procedure level, is in fact the direct cause of the collision. This failure must not be swept under the rug, or minimized with excessive emphasis on other issues.

NTSB Also Points the Finger at FRA for Derailment

In addition to blaming Amtrak’s safety culture, the NTSB found that the Federal Railroad Administration failed to require redundant signal protection, which could have prevented the train accident. The FRA, for example, does not require shunting even though the NTSB recommends it.

“By delaying progressive system safety regulation, the Federal Railroad Administration has failed to maximize safety for the passenger rail industry and the traveling public,” the NTSB wrote.

Among the safety recommendations, the NTSB made were that the FRA requires railroads to install safety equipment to protect track workers. The NTSB also recommended that Amtrak:

  • Ensure on-track protection is not lost when a new shift begins work;
  • Prevent dispatchers from making personal telephone calls while on shift;
  • Prepare site-specific work plans for maintenance projects; and
  • Conduct a risk assessment for engineering projects.

Following the accident and calls for changes among rail safety advocates, the FRA changed its drug testing program to require track maintenance workers to undergo random drug testing. Before the Chester train crash, only train engineers had to undergo such tests.



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