NTSB faults track conditions in fatal 2021 Amtrak derailment

Poor track conditions led to the fatal 2021 Amtrak train derailment in Joplin, Montana, the National Transportation Safety Board announced yesterday.

NTSB investigators cited a combination of factors — including worn rail, vertical track deflection, subgrade instability and track misalignment — that led to the derailment of Amtrak’s westbound Empire Builder on Sept. 25, 2021, killing three passengers and injuring 49 other passengers and crew, NTSB officials said in a press release.

The train consisted of two locomotives and 10 rail cars. Eight cars derailed when the train was in a right-hand curve on main track owned by BNSF Railway Co.

NTSB Chair Jennifer Homendy implored track owners to ensure inspectors have enough time, support and resources to detect track conditions that require repair.

"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," Homendy said.

Worn rail needs to be replaced before the flange of a train wheel contacts the top of a rail joint bar. Excessive wheel flange contact can lead to increased wear and tear on the wheel and rail. Established rail wear limit regulations would have required replacement of the worn rail before wheel flanges contacted a four-bolt joint bar, NTSB investigators said.

NTSB investigators also said walking inspections are important to ensure an understanding of track conditions and that the track inspector’s workload likely prevented him from performing a timely walking inspection of the track in the area of the derailment. BNSF Railway’s lack of management of workloads for safety-related employees indicates a shortcoming in its safety culture, they said.

In an email to The New York Times, BNSF spokeswoman Lena Kent said that, while the company had not yet fully reviewed the report’s findings, the Class I is "committed to safety" across its network, the newspaper reported.

"BNSF inspections meet all federal requirements, and we are committed to timely maintenance, repair and replacement whenever issues or potential issues are detected," Kent said, according to the NYTimes.

Kent also said that before the NTSB report was released, BNSF had begun installing track inspection technology on locomotives and that more than 4,000 detectors had been installed on tracks to collect and send out information to help "optimize the safety and reliability of our network and equipment," the newspaper reported.

Contributing to the severity of passenger injuries was the failure of some of the train's windows to stay in place when the derailment occurred. Performance standards for window retention systems are needed to prevent passenger ejections, the NTSB said.

Investigators also found that the use of compartmentalization in Amtrak’s passenger rail cars did not adequately protect passengers from injury during the derailment, they added.

Amtrak issued the following statement in response to the NTSB’s report: "Amtrak appreciates the opportunity to participate in the investigation and we will review the recommendations. Amtrak will continue to work with all stakeholders to improve rail safety for the traveling public."

In response to its findings, the NTSB issued three new safety recommendations to the Federal Railroad Administration, one to all Class Is and intercity railroads and two to BNSF.

To the FRA, the NTSB recommended the agency require limits for rail head wear, as well as require that the regulations on replacing rail joints be applied to all rail joints in continuously welded rail track without exception.

To BNSF, the board recommended that the railroad evaluate completely the derailment curve to look for what caused the instability in the subgrade and to make appropriate repairs.

All Class Is and intercity railroad trains operating on main tracks should be equipped with technology to monitor and detect track defects earlier, reducing the likelihood of derailments, the NTSB recommended.

The board also reiterated recommendations that address retention of passenger windows in rail cars and the adequacy of compartmentalization in rail cars.