Metrolink Failed to Act on NTSB Recommendations Before Chatsworth Accident of September 2008

Former NTSB Chairman Jim Hall calls failure to act 'irresponsible'

Jan 20, 2010, 13:11 ET from Hall & Associates, LLC

WASHINGTON, Jan. 20 /PRNewswire/ -- The engineer's use of a cell phone has been widely publicized in connection with the head on collision between a Metrolink commuter train and a Union Pacific freight train in Chatsworth, Calif., in September 2008.  Jim Hall, who served as Chairman of the NTSB from 1994 to 2001, expressed concern that focusing too much attention on the cell phone issue may detract from the real lesson to be learned from the Chatsworth collision.  Hall believes that positive train control, a system of monitoring and controlling train movements that NTSB identified over three decades ago as the most effective way to avoid train-to-train collisions, could have prevented the Chatsworth accident regardless of other factors.  

Prior to the Chatsworth collision, the NTSB found that the lack of a positive train control system was a contributing factor in a 2002 Metrolink accident in Placentia, Calif.(1)  Positive train control systems were not required by law, but several railroads had taken steps to implement them because of lessons learned in past accidents -- not Metrolink.  "It is sad and unfortunate that the need for positive train control was so clearly pointed out by the NTSB after Placentia, yet almost six years later Metrolink had made no effort toward implementing a system that would have prevented this collision," said Hall, who issued numerous recommendations to rail authorities and operators calling for the safety technology.  Hall added that Metrolink's failure to implement positive train control after Placentia, in the face of clear direction from the NTSB, was "irresponsible," and "was a major factor in the Chatsworth collision".  

Hall also pointed out that the use of a cell phone by the Metrolink engineer did not violate any law or regulation at the time of the Chatsworth accident.  This has changed.  He said, "To the extent that cell phone use contributed to the accident, this issue has now been addressed voluntarily by the FRA following the Chatsworth collision."  Hall stated that the FRA issued Emergency Order 26 in October 2008, a month after Chatsworth, which restricts cell phone use by on-duty railroad operating employees.  While Connex Railroad, the operator of the Metrolink train, had its own policies and oversight to restrict cell phone use, "there is no doubt that regulations with the force of law are more effective than procedures and policies alone," said Hall.  In fact, documents which have been publicly released by the NTSB show that the crew of the Union Pacific train were also violating operating rules by using a cell phone to send a text message in the minutes leading up to the fatal collision.  Nevertheless, Hall remains doubtful that cell phone use can be blamed for the Chatsworth collision.  Hall pointed out that the Metrolink engineer was attentive to his duties and operated the train as if he had seen a green signal during a significant period of time in which there was no evidence of cell phone use.  Four other witnesses who saw the signal when the train left the Chatsworth station also told the NTSB that they were certain it was green.  No one has come forward who claims to have seen a red signal.

The consistent eyewitness reports that the signal was green bring Hall back to the critical importance of positive train control, which can use GPS systems to automatically stop trains that are heading toward each other on the same track regardless of the reason.  "Whether the signal at Chatsworth was green or red, whether the trains were on the same track due to signal malfunction or human error, it is almost certain that the right kind of positive train control would have altogether avoided this catastrophe.  This accident put an exclamation point on the need for positive train control and the importance of redundancy to safety, and it is my sincere hope that this vital lesson will not again be lost on Metrolink."  

About Jim Hall

Jim Hall is managing partner at Hall and Associates LLC in Washington, D.C.  A former Chairman of the National Transportation Safety Board (NTSB), Hall is an expert on transportation safety, and has given congressional testimony before numerous House and Senate committees, including the House Committee on Transportation and Infrastructure and the Senate Committee on Commerce, Science and Transportation.  He is currently consulting with Connex Railroad in connection with the Chatsworth collision.

(1) NTSB Railroad Accident Report 03/04, adopted October 7, 2003. http://www.ntsb.gov/publictn/2003/RAR0304.pdf

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