Human Error Ruled Cause of Silver Star Crash

The National Transportation Safety Board has concluded that human error led to the February 2018 collision in South Carolina of an Amtrak train and a parked CSX train.

Two Amtrak crew members were killed in the collision and 74 others aboard the train were injured.

The accident happened when Amtrak’s southbound Silver Star was routed into a siding where the CSX train was sitting unattended in Cayce, South Carolina.

The NTSB investigation determined that the conductor of the CSX train had reported to the train’s engineer that a switch from the main to the siding had been realigned for the main.

The engineer in turn relayed that information to a dispatcher. However, the conductor had not realigned the switch.

At the time of the collision, the signal system on a 23-mile segment of the Columbia Subdivision has been suspended while workers were installing equipment for positive train control.

Trains were being dispatched by track warrants given over the radio.

The NTSB also concluded that the collision occurred as a result of inadequate attention to safety risks.

The board concluded that CSX failed to identify and mitigate the risk of operating trains while the signal system was under suspension.

Killed in the collision was the Amtrak engineer and conductor, who on the head end to copy train orders.

The Silver Star was traveling at more than 50 miles per hour when it struck CSX local F777.

“CSX failed to ensure that this crew was properly prepared to perform the tasks CSX assigned them to do that night,” said NTSB Chairman Robert Sumwalt, about the events leading to the Feb. 4, 2018, collision.

In the wake of the Silver Star accident, the NTSB asked the Federal Railroad Administration to issue an emergency order requiring railroads to operate trains at restricted speed approaching switches when a signal suspension is in effect.

In response the FRA issued an advisory to that effect, but not a rule. The NTSB in its final report repeated its recommendation that this be made a rule.

The NTSB also said the FRA could do more to prevent accident caused by misaligned switches, such as requiring the installation of switch position indicators.

In the Silver Star investigation, NTSB personnel found that CSX never conducted efficiency testing, or a skills assessment, on either the engineer or conductor of F777 for the purposes of ensuring proper switch alignment.

“I believe that the conductor had every intention of following the rules and thought that he did,” Mike Hoepf a consultant on human performance told NTSB. “He just made a mistake.”

The final NTSB report also called into question the effectiveness of using a Switch Position Awareness Form to mitigate the risk of an improperly lined switch.

No such form used by the F777 crew on that day was found by NTSB investigators.

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