2008 Chatsworth train collision
Encyclopedia
The Chatsworth train collision occurred at 16:22 PDT
(23:22 UTC
) on Friday September 12, 2008, when a Union Pacific
freight train
and a Metrolink
commuter train collided head-on
in the Chatsworth
district of Los Angeles
, California
, in the United States. The scene of the accident was a curved section of single track
on the Metrolink Ventura County Line just east of Stoney Point
.
According to the National Transportation Safety Board
(NTSB), which investigated the cause of the collision, the Metrolink train ran through a red signal
before entering a section of single track where the opposing freight train had been given the right of way by the train dispatcher
. The NTSB faulted the Metrolink train's engineer for the collision, concluding that he was distracted by text messages
he was sending while on duty.
This mass casualty event brought a massive emergency response by both the city and county of Los Angeles, but the nature and extent of physical trauma
taxed the available resources. With 25 deaths, this became the deadliest accident in Metrolink's history. Many survivors remained hospitalized for an extended period. Lawyers quickly began filing claims against Metrolink, and in total, they are expected to exceed a US$200 million liability limit set in 1997, portending the first legal challenges to that law. Issues surrounding this accident have also initiated and reinvigorated public debate on a range of topics including public relations
, safety
, and emergency management
, which has also resulted in regulatory and legislative actions.
commuter train 111, consisting of a 250000 pounds (113,398.1 kg) EMD F59PH
locomotive (SCAX 855) pulling three Bombardier BiLevel Coach
es, departed Union Station
in downtown Los Angeles
at 15:35 PDT (22:35 UTC) heading westbound to Moorpark
in suburban Ventura County
. Approximately 40 minutes later, it departed the Chatsworth station
with 222 people aboard, and had traveled approximately 1.25 miles (2 km) when it collided head-on with an eastbound Union Pacific
local freight train. The freight train was led by two SD70ACe
locomotives, UP 8485 and 8491, weighing more than 500000 pounds (226,796.2 kg) each. The Metrolink locomotive telescoped
into the passenger compartment of the first passenger car and caught fire. All three locomotives, the leading Metrolink passenger car and seven freight cars, were derailed
, and both lead locomotives and the passenger car fell over.
The collision occurred after the Metrolink passenger train engineer, 46-year-old Robert M. Sanchez, failed to obey a red, stop signal
that indicated it was not safe to proceed into the single track section. The train dispatcher
's computer at a remote control center in Pomona
did not display a warning prior to the accident according to the NTSB. Metrolink initially reported that the dispatcher tried in vain to contact the train crew to warn them; but the NTSB contradicted this report, saying the dispatcher noticed a problem only after the accident, and was notified by the passenger train's conductor
first.
Both trains were moving toward each other at the time of the collision. At least one passenger on the Metrolink train reported seeing the freight train moments before impact, coming around the curve. The conductor of the passenger train, who was in the rear car and was injured in the accident, estimated that his train was traveling at 40 miles per hour (17.9 m/s) before it suddenly came to a dead stop after the collision. The NTSB reported that it was traveling at 42 miles per hour (18.8 m/s). The freight was traveling at approximately the same speed after its engineer triggered the emergency air brake only two seconds before impact, while the Metrolink engineer never applied the brakes on his train.
near the intersection of Heather Lee Lane and Andora Avenue near Chatsworth Hills Academy
. The accident was in Chatsworth
, a neighborhood of Los Angeles located at the western edge of the San Fernando Valley
. The trains collided on the Metrolink Ventura County Line, part of the Montalvo Cutoff, opened by the Southern Pacific Company on March 20, 1904, to improve the alignment of its Coast Line. Metrolink has operated the line since purchasing it in the 1990s from Southern Pacific (now owned by Union Pacific), which retained trackage rights for freight service.
(which is double tracked) through the Santa Susana Pass
. The line returns to double track again as it enters the Simi Valley
. Three tunnels under the pass are only wide enough to support a single track, and it would be very costly to widen them. This single track section carries 24 passenger trains and 12 freight trains each day.
The line's railway signaling system is designed to ensure that trains wait on the double track section while a train is proceeding in the other direction on the single track. The signal system was upgraded in the 1990s to support Metrolink commuter rail services, and Richard Stanger, the executive director of Metrolink in its early years of 1991 to 1998, said the system had functioned without trouble in the past. The Metrolink train would normally wait in the Chatsworth station for the daily Union Pacific freight train to pass before proceeding, unless the freight train was already waiting for it at Chatsworth. The location was not protected by catch points.
The events on September 12, 2008 leading up to the collision (all times local):
(LAFD) originally dispatched a single engine company with a four person crew for a "possible physical rescue" at a residential address near the scene in response to a 9-1-1
emergency call from the home. The crew arrived at the address four minutes later, just before 16:30 PDT and accessed the scene by cutting through the backyard fence. Upon arrival, the captain on the scene immediately called for an additional five ambulances, then 30 fire engines, and after reaching the wreck he called for every heavy search and rescue unit in the city. Hundreds of emergency workers were eventually involved in the rescue and recovery efforts, including 250 firefighters.
The event was operationally identified as the "Chatsworth Incident" and was reclassified as a "mass casualty incident." All six of LAFD's air ambulances were mobilized, along with six additional helicopters from the Los Angeles County Fire Department
and the Los Angeles County Sheriff's Department
. The helicopters were requested under a mutual aid
arrangement.
A review of the emergency response and the on-site and hospital care was initiated by the Los Angeles County Supervisor immediately after the event, and was expected to take 90 days to complete.
A total of 25 people died in the collision, including engineer Sanchez and two victims who died at hospitals in the days following the crash. This event is the deadliest railway accident in Metrolink's history, and the worst in the United States since the Big Bayou Canot train disaster
in 1993.
A total of 135 others were reported injured, 46 of them critically, with 85 of the injured transported to 13 hospitals and two transported themselves. Air ambulance
helicopters medevaced 40 patients. LAFD Captain Steve Ruda reported that the high number of critically injured passengers taxed the area's emergency response capabilities, and patients were distributed to all 12 trauma center
s in Los Angeles County
. Providence Holy Cross Medical Center
in Mission Hills
treated 17 patients, more than any other hospital.
Captain Ruda said his firefighters had never seen such carnage. Austin Walbridge, a train passenger, told a TV news reporter that the interior of the train was "bloody, a mess. Just a disaster. It was horrible." Emergency responders described the victims as having crush type injuries. Dr. Amal K. Obaid, a trauma surgeon
who practices at USC University Hospital
where several victims were treated, described their injuries in more detail, "They have head injuries
, multiple facial fractures, chest trauma
, collapsed lungs
, rib fracture
s, pelvic fracture
s, leg and arm fractures
, cuts in the skin
and soft tissue. Some have blood in the brain
."
The Los Angeles County Coroner
set up an air-conditioned tent that functioned as a temporary morgue at the site. One off-duty Los Angeles Police Department
officer was among the confirmed deaths, as was the Metrolink train's engineer,
an employee of Veolia Transportation, a contracted operator of Metrolink.
One of the passengers who died was a survivor of the 2005 Glendale train crash.
Another had been commuting by train since Metrolink's inception in 1992.
Many victims were residents of suburban Simi Valley and Moorpark on their way home from work in the Los Angeles area.
The four other crew members of the two trains survived.
The conductor and engineer of the freight train were trapped inside the lead locomotive while it was engulfed in flames; the firefighters who rescued the pair found them banging on the thick glass windshield, unable to escape. The freight crew also had a brakeman
riding in the second locomotive who was injured in the crash.
The search for victims came to an end shortly after 14:30 PDT on September 13, approximately 22 hours after the collision.
and the Coast Starlight
. Amtrak
canceled service on the Pacific Surfliner between San Luis Obispo
and Union Station in Los Angeles and Thruway Motorcoach buses transported Coast Starlight passengers from Union Station to Santa Barbara
to board the trains. Metrolink service on the Ventura County Line was interrupted north of Chatsworth, and all service resumed four days after the accident.
, which indicated his train did not have permission to proceed. She was quoted as saying, "We don't know how the error happened, but this is what we believe happened. We believe it was our engineer who failed to stop at the signal." Tyrrell said that if the engineer obeyed the signal, the accident would not have occurred. However Los Angeles County Supervisor
and Metrolink board member Don Knabe
said it was premature to blame the engineer, speculating that "there could always be a technical malfunction where... there was a green light both ways."
After a Metrolink board meeting two days after her remarks, Tyrrell resigned. Tyrrell stated that she quit because a Metrolink Board statement called her announcement premature, and inappropriate; she maintained that it was proper to get out in front of the story before the NTSB took over the investigation. She stated that she asked for and received authorization to make the comments from David Solow, Metrolink's chief executive. Solow confirmed that he did give authorization, but said in hindsight he would not have given permission. After her resignation, some good government
proponents praised Tyrrell for her candor, including the chief public advocate with California Common Cause
. The Los Angeles Times
also published an editoral by columnist Patt Morrison
sympathetic to Tyrrell's position, in which she says, "I am unclear of the concept of how the truth can somehow be premature. The truth is the truth."
Tests of the railway signal system after the accident showed it was working properly, and should have shown proper signal indications to the Metrolink train, with two yellow signals as the train approached the Chatsworth station, and a red signal at the switch north of the station. "We can say with confidence that the signal system was working," the lead NTSB board member stated at a news conference after the tests. This focused the NTSB investigation on human factors
.
Before releasing the accident scene and allowing restoration of service, the NTSB also conducted a final sight distance
test. An identical Metrolink train and pair of Union Pacific locomotives were brought together at the point of impact and slowly backed away from each other. The test showed that the trains' engineers could not see each other until less than five seconds before the collision.
The surviving crew members could not be interviewed by the NTSB immediately after the accident because they were still recovering from their injuries. The NTSB was able to interview the Metrolink conductor about recorded radio communications, which did not capture the required communication between the conductor and engineer on the aspects displayed by the last two signals the train passed before the accident. He confirmed they did not call out the last two signals.
The NTSB also stated that a railroad switch
showed evidence of damage consistent with the Metrolink passenger train "running through" the trailing switch points while they were set to allow the freight train to proceed onto the adjacent track, forcing them out of the way. "The switch bars were bent like a banana. It should be perfectly straight," according to the NTSB official. The NTSB member in charge of the investigative team said they were also concerned with possible fatigue issues related to the engineer's split shift
. The engineer worked an 11.5-hour shift split with a 3.5-hour break, leaving only nine hours away from work between workdays.
The Federal Railroad Administration
(FRA) is also investigating to determine if any federal safety regulations were violated. The California Public Utilities Commission
, the state agency responsible for regulating railroads, also reported that it has ten investigators with railroad experience working in conjunction with the NTSB, and will also be looking into the matter of the Tyrrell resignation.
Before the conclusion of the formal investigation, three witnesses came forward to say that they observed the signal to be green as the Metrolink train departed the Chatsworth station just before the collision. A newspaper reporter interviewed the witnesses at the station, and confirmed that the signal was visible from the station, and that the witnesses could correctly identify the colors displayed. A safety consultant said that although this type of signal failure is extremely rare, he had seen it twice before in his 13-year career as a locomotive engineer. The NTSB considered the eyewitness' accounts and, based on the results of its tests of the signal system and on the distance between the witnesses and the signal, rejected them as "contrary to the other evidence".
Local television news broke the story that the Metrolink engineer was exchanging brief text messages
with a teenage train enthusiast
while operating the train, a violation of Metrolink rules according to the agency. The last message received from the engineer, time-stamped one minute before the collision, reportedly said, "yea ... usually @ north camarillo," apparently a reference to a town further down the line where the engineer expected to meet another train.
The NTSB did not recover the engineer's cellphone in the wreckage and said the teenagers were cooperating with the investigation, initially noting that similar rumors about an engineer using a cell phone from an investigation recently conducted in Boston were unfounded. After receiving the engineer's cell phone records under subpoena, the NTSB confirmed that engineer was texting while on duty, but had not yet correlated the messages with the accident timeline. After completing a preliminary timeline, the NTSB placed the last text message sent by the engineer at 22 seconds before impact.
An NTSB representative refused to comment further on the preliminary timeline, which investigators were still refining. Two University of Southern California academics used the information in the NTSB statement to determine that the last text message sent by the Metrolink train's engineer would have been sent a few seconds after he had passed the last red signal. This would make unconsciousness
an unlikely cause for this error, since the engineer was able to compose and send the message; instead a psychology professor from the University of Utah
raised the possibility that "inattention blindness" caused the engineer to fail to see the signal.
The day after the NTSB confirmed the engineer was texting, and less than one week after the accident, the California Public Utilities Commission unanimously passed an emergency order to temporarily ban the use of cellular communication devices by train crew members, citing this accident and a previous San Francisco Municipal Railway
accident where the train operator was using a cell phone.
A week later, texting while driving
an automobile was outlawed in California, effective January 1, 2009.
There was no federal regulation prohibiting cell phone use by train crews at the time of the accident, but the NTSB had recommended the Federal Railroad Administration address the issue in 2003, after concluding cell phone use by a freight train engineer contributed to a fatal head-on train collision in Texas
in 2002. However, 19 days after the accident the FRA administrator issued Emergency Order No. 26 restricting the use of "personal electronic or electrical devices" by railroad operating employees.
On March 3, 2009 federal investigators released records showing that the train engineer Robert M. Sanchez had allowed a train enthusiast to ride in the cab several days before the crash, and that he was planning to let him run the train between four stations on the evening of the crash. "I'm gonna do all the radio talkin' ... ur [sic] gonna run the locomotive & I'm gonna tell u [sic] how to do it," Sanchez wrote in one text. Records also show Sanchez had received two prior warnings from his supervisors about improper use of cellphones while in the control cab.
(apply the brakes) should the engineer appear to be incapacitated for any reason. However, in this incident, according to the data video, the last two signals were not reported, nor did the conductor apply the brakes.
Unusually, the conductor told the engineer that the starting signal was green, rather than the other way around.
into the path of the oncoming Union Pacific freight train. The investigation has led the NTSB to recommend that the federal government require the installation of video and audio recording equipment to be installed in all locomotive and train operating cabs.
(PTC), a safety backup system that can automatically stop a train. Federal Railroad Administrator Joseph H. Boardman
told a reporter days after the accident that PTC "would have stopped the train before there was a collision." The National Transportation Safety Board (NTSB) member leading the investigation also said she was convinced that such a system "would have prevented this accident." These systems are not widely deployed yet, and would require a multi-billion US dollar investment to reach that goal nationwide. A Metrolink board member acknowledged they were studying this technology, but said that press reports implying that PTC systems were available off the shelf
are misleading, and denied that cost was the primary reason it has not been deployed there. PTC has been on the NTSB's most wanted safety improvements list since 2001.
At the next regularly scheduled Metrolink board meeting after the accident, the board decided not to wait for PTC to be ready for deployment before making system safety improvements; instead Metrolink will expand the existing automated train stop system used on 30 miles (48.3 km) of Metrolink track in Orange County
across its 350 miles (563.3 km) system. Metrolink's automated train stop system will automatically apply the brakes to stop a train if the engineer fails to respond to a warning within eight seconds. It was originally installed in the 1950s by the Atchison, Topeka and Santa Fe Railway
to allow trains to operate at speeds of over 79 mph under regulations imposed by the Interstate Commerce Commission
, a former federal regulatory body whose safety functions have since been assumed by the Federal Railroad Administration
. Metrolink is also adding a second engineer to some trains to improve safety.
An issue likely to come into play will be a provision in the Amtrak Reform and Accountability Act of 1997 (P.L. 105-134), which places a US$
200 million cap on the aggregate of all passengers' damage claims in a railroad accident against a passenger railroad, including punitive damages. Bloomberg News
reported that this event would likely be the first legal test of this law, according to a former House rail committee
staffer who helped write the law, who predicted that given the number of casualties, the cap is almost certainly going to be an issue in pending litigation. An attorney representing two of the victims agreed, saying payouts could range from $5 million to $10 million per death or serious injury. Metrolink reportedly has insurance coverage totaling $150 million.
The California Government Claims Act prescribes a six-month deadline for initiating claims for personal injury or wrongful death against government agencies after an accident, so time was of the essence for plaintiffs as well as their legal advocates. However, the aggressive tactics of some lawyers led the State Bar of California
to publicly warn its members that unsolicited contact with a potential client is both illegal and unethical.
in New York
, said that it had studied positive train control
, but decided to stick with its "automatic speed control system," a form of cab signaling with automatic train stop
using technology that is more than 50 years old. The San Diego
's Coaster commuter line also has an automatic train stop system that a spokesman said will stop the train automatically if the engineer fails to stop at a red stop signal.
Boston's MBTA
says its "Cab Signal with Positive Stop" system can stop a train that passes a stop signal or when another train is in its path; the system averted disaster in March 2008 when it stopped a train heading for a runaway freight car. The Southeastern Pennsylvania Transportation Authority had Automatic Train Control
on 80% of its system, and was planning to install it in the other 20% by 2014.
The Denver
area Regional Transportation District
said that its FasTracks
commuter rail program has been designed to limit exposure to freight traffic by using physical separation with separate freight and passenger tracks where possible and using temporal separation by running passenger trains during the day, and freight at night and between rush hours. The San Jose Mercury News
reported that San Francisco Bay Area
Caltrain
commuters are much less likely to be in a head-on collision because opposing trains usually run on separate tracks, and runs freight only at night on a large portion of its route. The North County Transit District
's spokesman for its Sprinter service in San Diego also said it runs freight only at night when passenger service is suspended.
. On September 8, 2009, the first permanent memorial, a plaque, was placed in Union Station
. The Metrolink Memorial Plaza was dedicated on September 12, 2009 at the Simi Valley station. The plaza features 11 columns, one each for the ten deceased passengers from Simi Valley and an additional one for the 14 other deceased victims. There are also 25 markers on the grounds to commemorate each victim as well as a seating area and a plaque in remembrance to the 2005 Glendale train crash. Two days later, on the one-year anniversary of the crash a memorial ceremony was held at Stony Point Park, near the location of the collision.
Pacific Time Zone
The Pacific Time Zone observes standard time by subtracting eight hours from Coordinated Universal Time . The clock time in this zone is based on the mean solar time of the 120th meridian west of the Greenwich Observatory. During daylight saving time, its time offset is UTC-7.In the United States...
(23:22 UTC
Coordinated Universal Time
Coordinated Universal Time is the primary time standard by which the world regulates clocks and time. It is one of several closely related successors to Greenwich Mean Time. Computer servers, online services and other entities that rely on having a universally accepted time use UTC for that purpose...
) on Friday September 12, 2008, when a Union Pacific
Union Pacific Railroad
The Union Pacific Railroad , headquartered in Omaha, Nebraska, is the largest railroad network in the United States. James R. Young is president, CEO and Chairman....
freight train
Freight train
A freight train or goods train is a group of freight cars or goods wagons hauled by one or more locomotives on a railway, ultimately transporting cargo between two points as part of the logistics chain...
and a Metrolink
Metrolink (Southern California)
Metrolink is a commuter rail system serving Los Angeles and the surrounding area of Southern California; it currently consists of six lines and 55 stations using of track....
commuter train collided head-on
Head-on collision
A head-on collision is one where the front ends of two ships, trains, planes or vehicles hit each other, as opposed to a side collision or rear-end collision.-Rail transport:...
in the Chatsworth
Chatsworth, Los Angeles, California
Chatsworth is a district of Los Angeles, California, United States; in the northwestern San Fernando Valley. The district is bordered by the Santa Susana Mountains and unincorporated Los Angeles County lands to the north, Porter Ranch to the northeast, Northridge to the east, West Hills, Canoga...
district of Los Angeles
Los Ángeles
Los Ángeles is the capital of the province of Biobío, in the commune of the same name, in Region VIII , in the center-south of Chile. It is located between the Laja and Biobío rivers. The population is 123,445 inhabitants...
, California
California
California is a state located on the West Coast of the United States. It is by far the most populous U.S. state, and the third-largest by land area...
, in the United States. The scene of the accident was a curved section of single track
Single track (rail)
A single track railway is where trains in both directions share the same track. Single track is normally used on lesser used rail lines, often branch lines, where the traffic density is not high enough to justify the cost of building double tracks....
on the Metrolink Ventura County Line just east of Stoney Point
Stoney Point (California)
Stoney Point, also known as the Stoney Point Outcroppings, is a city park near the north end of Topanga Canyon Boulevard in Chatsworth, California...
.
According to the National Transportation Safety Board
National Transportation Safety Board
The National Transportation Safety Board is an independent U.S. government investigative agency responsible for civil transportation accident investigation. In this role, the NTSB investigates and reports on aviation accidents and incidents, certain types of highway crashes, ship and marine...
(NTSB), which investigated the cause of the collision, the Metrolink train ran through a red signal
Signal passed at danger
A Signal passed at danger , in British railway terminology, occurs when a train passes a stop signal without authority to do so. It is a term primarily used within the British Railway Industry, although it can be applied worldwide.-Categories of SPAD:...
before entering a section of single track where the opposing freight train had been given the right of way by the train dispatcher
Train dispatcher
A train dispatcher is employed by a railroad to direct and facilitate the movement of trains over an assigned territory, which is usually part, or all, of a railroad operating division. In Canada the train dispatcher is known as the rail traffic controller...
. The NTSB faulted the Metrolink train's engineer for the collision, concluding that he was distracted by text messages
Text messaging
Text messaging, or texting, refers to the exchange of brief written text messages between fixed-line phone or mobile phone and fixed or portable devices over a network...
he was sending while on duty.
This mass casualty event brought a massive emergency response by both the city and county of Los Angeles, but the nature and extent of physical trauma
Physical trauma
Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...
taxed the available resources. With 25 deaths, this became the deadliest accident in Metrolink's history. Many survivors remained hospitalized for an extended period. Lawyers quickly began filing claims against Metrolink, and in total, they are expected to exceed a US$200 million liability limit set in 1997, portending the first legal challenges to that law. Issues surrounding this accident have also initiated and reinvigorated public debate on a range of topics including public relations
Public relations
Public relations is the actions of a corporation, store, government, individual, etc., in promoting goodwill between itself and the public, the community, employees, customers, etc....
, safety
Safety
Safety is the state of being "safe" , the condition of being protected against physical, social, spiritual, financial, political, emotional, occupational, psychological, educational or other types or consequences of failure, damage, error, accidents, harm or any other event which could be...
, and emergency management
Emergency management
Emergency management is the generic name of an interdisciplinary field dealing with the strategic organizational management processes used to protect critical assets of an organization from hazard risks that can cause events like disasters or catastrophes and to ensure the continuance of the...
, which has also resulted in regulatory and legislative actions.
Collision
MetrolinkMetrolink (Southern California)
Metrolink is a commuter rail system serving Los Angeles and the surrounding area of Southern California; it currently consists of six lines and 55 stations using of track....
commuter train 111, consisting of a 250000 pounds (113,398.1 kg) EMD F59PH
EMD F59PH Series Locomotives
The EMD F59PH series of locomotives comprises two variants of locomotives built by EMD, the original F59PH and the newer F59PHI. These modern diesel-electric locomotives are popular among North American commuter rail services.-F59PH:...
locomotive (SCAX 855) pulling three Bombardier BiLevel Coach
Bombardier BiLevel Coach
Bombardier BiLevel coaches are bilevel passenger cars designed to carry up to 360 passengers for regional railways. These carriages are easily identifiable; they are double-decked and are shaped like elongated octagons.-History:...
es, departed Union Station
Union Station (Los Angeles)
Los Angeles Union Station is the main railway station in Los Angeles, California. The station has rail services by Amtrak and Amtrak California and Metrolink; light rail/subways are the Metro Rail Red Line, Purple Line, Gold Line. Bus rapid transport runs on the Silver Line...
in downtown Los Angeles
Downtown Los Angeles
Downtown Los Angeles is the central business district of Los Angeles, California, United States, located close to the geographic center of the metropolitan area...
at 15:35 PDT (22:35 UTC) heading westbound to Moorpark
Moorpark (Amtrak station)
The Moorpark Amtrak/Metrolink Station is an Amtrak and Metrolink rail station in the city of Moorpark, California.It is served by both Amtrak's Pacific Surfliner from San Luis Obispo to San Diego and Metrolink's Ventura County Line from Los Angeles Union Station to East Ventura. Five Pacific...
in suburban Ventura County
Ventura County, California
Ventura County is a county in the southern part of the U.S. state of California. It is located on California's Pacific coast. It is often referred to as the Gold Coast, and has a reputation of being one of the safest populated places and one of the most affluent places in the country...
. Approximately 40 minutes later, it departed the Chatsworth station
Chatsworth (Amtrak station)
The Chatsworth Amtrak/Metrolink Station, sometimes referred to as the Chatsworth Transportation Center, is an Amtrak and Metrolink rail station in the Los Angeles community of Chatsworth, California, USA. It is served by both Amtrak's Pacific Surfliner from San Luis Obispo to San Diego and...
with 222 people aboard, and had traveled approximately 1.25 miles (2 km) when it collided head-on with an eastbound Union Pacific
Union Pacific Railroad
The Union Pacific Railroad , headquartered in Omaha, Nebraska, is the largest railroad network in the United States. James R. Young is president, CEO and Chairman....
local freight train. The freight train was led by two SD70ACe
EMD SD70 series
The EMD SD70 is a series of diesel-electric locomotives produced by the Electro-Motive Division of General Motors beginning in 1992. Over 4000 locomotives in this series have been produced, mostly of the SD70M and SD70MAC models. All locomotives of this series are hood units with C-C trucks...
locomotives, UP 8485 and 8491, weighing more than 500000 pounds (226,796.2 kg) each. The Metrolink locomotive telescoped
Telescoping (railway)
In a railway accident, telescoping occurs when the underframe of one vehicle overrides that of another, and smashes through the second vehicle's body...
into the passenger compartment of the first passenger car and caught fire. All three locomotives, the leading Metrolink passenger car and seven freight cars, were derailed
Derailment
A derailment is an accident on a railway or tramway in which a rail vehicle, or part or all of a train, leaves the tracks on which it is travelling, with consequent damage and in many cases injury and/or death....
, and both lead locomotives and the passenger car fell over.
The collision occurred after the Metrolink passenger train engineer, 46-year-old Robert M. Sanchez, failed to obey a red, stop signal
Signal passed at danger
A Signal passed at danger , in British railway terminology, occurs when a train passes a stop signal without authority to do so. It is a term primarily used within the British Railway Industry, although it can be applied worldwide.-Categories of SPAD:...
that indicated it was not safe to proceed into the single track section. The train dispatcher
Train dispatcher
A train dispatcher is employed by a railroad to direct and facilitate the movement of trains over an assigned territory, which is usually part, or all, of a railroad operating division. In Canada the train dispatcher is known as the rail traffic controller...
's computer at a remote control center in Pomona
Pomona, California
-2010:The 2010 United States Census reported that Pomona had a population of 149,058, a slight decline from the 2000 census population. The population density was 6,491.2 people per square mile...
did not display a warning prior to the accident according to the NTSB. Metrolink initially reported that the dispatcher tried in vain to contact the train crew to warn them; but the NTSB contradicted this report, saying the dispatcher noticed a problem only after the accident, and was notified by the passenger train's conductor
Conductor (transportation)
A conductor is a member of a railway train's crew that is responsible for operational and safety duties that do not involve the actual operation of the train. The title of conductor is most associated with railway operations in North America, but the role of conductor is common to railways...
first.
Both trains were moving toward each other at the time of the collision. At least one passenger on the Metrolink train reported seeing the freight train moments before impact, coming around the curve. The conductor of the passenger train, who was in the rear car and was injured in the accident, estimated that his train was traveling at 40 miles per hour (17.9 m/s) before it suddenly came to a dead stop after the collision. The NTSB reported that it was traveling at 42 miles per hour (18.8 m/s). The freight was traveling at approximately the same speed after its engineer triggered the emergency air brake only two seconds before impact, while the Metrolink engineer never applied the brakes on his train.
Location
The accident occurred after the freight train emerged from the 500-foot-long (150-meter-long) tunnel #28, just south of California State Route 118California State Route 118
State Route 118 is a state highway in the U.S. state of California that begins running west to east through Ventura and Los Angeles counties in southern California. It travels from Saticoy in Ventura County east to Lake View Terrace in Los Angeles...
near the intersection of Heather Lee Lane and Andora Avenue near Chatsworth Hills Academy
Chatsworth Hills Academy
Chatsworth Hills Academy is a private, coeducational day school located in Chatsworth, California, USA. CHA students are enrolled in Grades K through Eight and Preschool....
. The accident was in Chatsworth
Chatsworth, Los Angeles, California
Chatsworth is a district of Los Angeles, California, United States; in the northwestern San Fernando Valley. The district is bordered by the Santa Susana Mountains and unincorporated Los Angeles County lands to the north, Porter Ranch to the northeast, Northridge to the east, West Hills, Canoga...
, a neighborhood of Los Angeles located at the western edge of the San Fernando Valley
San Fernando Valley
The San Fernando Valley is an urbanized valley located in the Los Angeles metropolitan area of southern California, United States, defined by the dramatic mountains of the Transverse Ranges circling it...
. The trains collided on the Metrolink Ventura County Line, part of the Montalvo Cutoff, opened by the Southern Pacific Company on March 20, 1904, to improve the alignment of its Coast Line. Metrolink has operated the line since purchasing it in the 1990s from Southern Pacific (now owned by Union Pacific), which retained trackage rights for freight service.
Railroad physical characteristics
Both trains were on the same section of single track that runs between the Chatsworth stationChatsworth (Amtrak station)
The Chatsworth Amtrak/Metrolink Station, sometimes referred to as the Chatsworth Transportation Center, is an Amtrak and Metrolink rail station in the Los Angeles community of Chatsworth, California, USA. It is served by both Amtrak's Pacific Surfliner from San Luis Obispo to San Diego and...
(which is double tracked) through the Santa Susana Pass
Santa Susana Pass
The Santa Susana Pass is a Southern California mountain pass in the Simi Hills connecting the San Fernando Valley and town of Chatsworth, to the Simi Valley and city of Simi Valley.-Natural history:...
. The line returns to double track again as it enters the Simi Valley
Simi Valley
Simi Valley is a synclinal valley in Southern California in the United States. It is an enclosed or hidden valley surrounded by mountains and hills. It is connected to the San Fernando Valley to the east by the Santa Susana Pass & 118 freeway, and in the west the narrows of the Arroyo Simi and 118...
. Three tunnels under the pass are only wide enough to support a single track, and it would be very costly to widen them. This single track section carries 24 passenger trains and 12 freight trains each day.
The line's railway signaling system is designed to ensure that trains wait on the double track section while a train is proceeding in the other direction on the single track. The signal system was upgraded in the 1990s to support Metrolink commuter rail services, and Richard Stanger, the executive director of Metrolink in its early years of 1991 to 1998, said the system had functioned without trouble in the past. The Metrolink train would normally wait in the Chatsworth station for the daily Union Pacific freight train to pass before proceeding, unless the freight train was already waiting for it at Chatsworth. The location was not protected by catch points.
Timeline
| Station | Time |
|---|---|
| Union Station Union Station (Los Angeles) Los Angeles Union Station is the main railway station in Los Angeles, California. The station has rail services by Amtrak and Amtrak California and Metrolink; light rail/subways are the Metro Rail Red Line, Purple Line, Gold Line. Bus rapid transport runs on the Silver Line... |
15:35 |
| Glendale Glendale (Amtrak station) The Glendale Amtrak/Metrolink Station, often referred to as the Glendale Transportation Center, is an Amtrak and Metrolink rail station in the city of Glendale, California... |
15:45 |
| Downtown Burbank Downtown Burbank (Metrolink station) The Burbank Metrolink Station, sometimes referred to as the Burbank Transportation Center, is a Metrolink rail station near downtown Burbank, California. It is served by Metrolink's Antelope Valley Line to Lancaster and Ventura County Line to Montalvo, Ventura and both terminating at Los Angeles... |
15:51 |
| Bob Hope Airport Bob Hope Airport Train Station Bob Hope Airport Train Station is an unstaffed Amtrak and Metrolink rail station at Bob Hope Airport in the city of Burbank, California. It is served by both Amtrak's Pacific Surfliner from San Luis Obispo to San Diego and Metrolink's Ventura County Line from Los Angeles Union Station to Montalvo... |
15:55 |
| Van Nuys Van Nuys (Amtrak station) The Van Nuys Amtrak/Metrolink Station is an Amtrak and Metrolink rail station in the community of Van Nuys in Los Angeles, California.The station is served by Amtrak's Pacific Surfliner from San Luis Obispo to San Diego, Amtrak's Coast Starlight from Los Angeles Union Station to Seattle,... |
16:02 |
| Northridge Northridge (Metrolink station) The Northridge Metrolink Station is a Metrolink rail station in the community of Northridge, California. It is served by Metrolink's Ventura County Line from Los Angeles Union Station to Montalvo. 20 Metrolink trains serve the station each weekday.... |
16:09 |
| Chatsworth Chatsworth (Amtrak station) The Chatsworth Amtrak/Metrolink Station, sometimes referred to as the Chatsworth Transportation Center, is an Amtrak and Metrolink rail station in the Los Angeles community of Chatsworth, California, USA. It is served by both Amtrak's Pacific Surfliner from San Luis Obispo to San Diego and... |
16:16 |
| Simi Valley Simi Valley (Amtrak station) The Simi Valley Amtrak/Metrolink Station is an Amtrak and Metrolink rail station in the city of Simi Valley. It is served by Amtrak's Pacific Surfliner from San Luis Obispo to San Diego, Amtrak's Coast Starlight from Los Angeles Union Station to Seattle, and Metrolink's Ventura County Line from Los... |
16:28 |
| Moorpark Moorpark (Amtrak station) The Moorpark Amtrak/Metrolink Station is an Amtrak and Metrolink rail station in the city of Moorpark, California.It is served by both Amtrak's Pacific Surfliner from San Luis Obispo to San Diego and Metrolink's Ventura County Line from Los Angeles Union Station to East Ventura. Five Pacific... |
16:45 |
The events on September 12, 2008 leading up to the collision (all times local):
| 05:54 | Engineer Sanchez begins his 11-hour split shift Split shift Split shift is an employment schedule, a type of shift work where a person's normal work day is split into two or more segments; for example a person may work from 5 a.m. to 9 a.m. and then have a break until 3 p.m. at which point he might return to work until 7 p.m... . |
|
| 06:44 | Sanchez begins his morning run. | |
| 08:53 | Sanchez finishes his morning run after exchanging 45 text messages while en route. | |
| 09:26 | Sanchez finishes the first part of his shift and goes off duty. | |
| 14:00 | Sanchez returns to work after reportedly taking a two-hour nap. | |
| 15:03 | Sanchez begins his afternoon run. | |
| 15:30 | Sanchez uses his cell phone to order a roast beef sandwich from a restaurant in Moorpark. | |
| 15:35 | Metrolink train #111 departs Union Station with Sanchez at the controls of locomotive #855. | |
| 16:13 | The signal north of the Chatsworth station is set to red to hold the Metrolink train. | |
| 16:16 | Train #111 is scheduled to depart Chatsworth station with the next stop in Simi Valley. | |
| 16:21:03 | Sanchez receives a seventh text message while en route. | |
| 16:22:01 | Sanchez sends the last of five text messages while en route, 22 seconds before impact. | |
| 16:22:19 | The locomotive crews can first see each other 4 seconds before impact. | |
| 16:22:21 | The Union Pacific freight engineer triggers the emergency brake 2 seconds before impact. | |
| 16:22:23 | The trains collide after Sanchez runs through a track switch without applying the brakes. |
Emergency response
The Los Angeles Fire DepartmentLos Angeles Fire Department
The Los Angeles Fire Department is the agency that provides fire protection and emergency medical services for the city of Los Angeles....
(LAFD) originally dispatched a single engine company with a four person crew for a "possible physical rescue" at a residential address near the scene in response to a 9-1-1
9-1-1
9-1-1 is the emergency telephone number for the North American Numbering Plan .It is one of eight N11 codes.The use of this number is for emergency circumstances only, and to use it for any other purpose can be a crime.-History:In the earliest days of telephone technology, prior to the...
emergency call from the home. The crew arrived at the address four minutes later, just before 16:30 PDT and accessed the scene by cutting through the backyard fence. Upon arrival, the captain on the scene immediately called for an additional five ambulances, then 30 fire engines, and after reaching the wreck he called for every heavy search and rescue unit in the city. Hundreds of emergency workers were eventually involved in the rescue and recovery efforts, including 250 firefighters.
The event was operationally identified as the "Chatsworth Incident" and was reclassified as a "mass casualty incident." All six of LAFD's air ambulances were mobilized, along with six additional helicopters from the Los Angeles County Fire Department
Los Angeles County Fire Department
The Los Angeles County Fire Department , serves unincorporated parts of Los Angeles County, as well as 58 cities and towns that choose to have the county provide fire and EMS services, including La Habra. It should not be confused with the Los Angeles City Fire Department, which serves the city of...
and the Los Angeles County Sheriff's Department
Los Angeles County Sheriff's Department
The Los Angeles County Sheriff's Department is a local county law enforcement agency that serves Los Angeles County, California. It is the fourth largest local policing agency in the United States, with the New York City Police Department being the first. The second largest is the Chicago Police...
. The helicopters were requested under a mutual aid
Mutual aid (emergency services)
In emergency services, mutual aid is an agreement among emergency responders to lend assistance across jurisdictional boundaries. This may occur due to an emergency response that exceeds local resources, such as a disaster or a multiple-alarm fire. Mutual aid may be ad hoc, requested only when...
arrangement.
A review of the emergency response and the on-site and hospital care was initiated by the Los Angeles County Supervisor immediately after the event, and was expected to take 90 days to complete.
Casualties
Big Bayou Canot train disaster
The 1993 Big Bayou Canot train wreck was the derailing of an Amtrak train on the CSXT Big Bayou Canot bridge in northeast Mobile, Alabama, USA, killing 47 and injuring 103, on September 22, 1993. It is the deadliest train wreck in Amtrak's history...
in 1993.
A total of 135 others were reported injured, 46 of them critically, with 85 of the injured transported to 13 hospitals and two transported themselves. Air ambulance
Air ambulance
An air ambulance is an aircraft used for emergency medical assistance in situations where either a traditional ambulance cannot reach the scene easily or quickly enough, or the patient needs to be transported over a distance or terrain that makes air transportation the most practical transport....
helicopters medevaced 40 patients. LAFD Captain Steve Ruda reported that the high number of critically injured passengers taxed the area's emergency response capabilities, and patients were distributed to all 12 trauma center
Trauma center
A trauma center is a hospital equipped to provide comprehensive emergency medical services to patients suffering traumatic injuries. Trauma centers grew into existence out of the realization that traumatic injury is a disease process unto itself requiring specialized and experienced...
s in Los Angeles County
Los Angeles County, California
Los Angeles County is a county in the U.S. state of California. As of 2010 U.S. Census, the county had a population of 9,818,605, making it the most populous county in the United States. Los Angeles County alone is more populous than 42 individual U.S. states...
. Providence Holy Cross Medical Center
Providence Holy Cross Medical Center
Providence Holy Cross Medical Center is a hospital in Mission Hills, California, USA. The hospital has 254 beds, and is part of Providence Health & Services.-History:...
in Mission Hills
Mission Hills, Los Angeles, California
Mission Hills is a suburban community in the San Fernando Valley region of the city of Los Angeles, California.It is located near the northern junction of the Golden State Freeway and the San Diego Freeway . The Ronald Reagan Freeway bisects the neighborhood. Mission Hills is the northern...
treated 17 patients, more than any other hospital.
Captain Ruda said his firefighters had never seen such carnage. Austin Walbridge, a train passenger, told a TV news reporter that the interior of the train was "bloody, a mess. Just a disaster. It was horrible." Emergency responders described the victims as having crush type injuries. Dr. Amal K. Obaid, a trauma surgeon
Trauma surgery
Trauma surgery is a surgical specialty involved in the invasive treatment of physical injuries, typically in an emergency setting. Trauma surgeons generally complete residency training in general surgery and often fellowship training in trauma or surgical critical care...
who practices at USC University Hospital
Los Angeles County-USC Medical Center
Los Angeles County+USC Medical Center, also known as County/USC, by the abbreviation LAC+USC, or by the name Los Angeles County General, is a 600-bed public teaching hospital located in the Boyle Heights neighborhood of Los Angeles, California...
where several victims were treated, described their injuries in more detail, "They have head injuries
Head injury
Head injury refers to trauma of the head. This may or may not include injury to the brain. However, the terms traumatic brain injury and head injury are often used interchangeably in medical literature....
, multiple facial fractures, chest trauma
Chest trauma
Chest trauma is a serious injury of the chest. Thoracic trauma is a common cause of significant disability and mortality, the leading cause of death from physical trauma after head and spinal cord injury. Blunt thoracic injuries are the primary or a contributing cause of about a quarter of all...
, collapsed lungs
Pneumothorax
Pneumothorax is a collection of air or gas in the pleural cavity of the chest between the lung and the chest wall. It may occur spontaneously in people without chronic lung conditions as well as in those with lung disease , and many pneumothoraces occur after physical trauma to the chest, blast...
, rib fracture
Rib fracture
A rib fracture is a break or fracture in one or more of the bones making up the rib cage.The first rib is rarely fractured because of its protected position behind the clavicle . However, if it is broken serious damage can occur to the brachial plexus of nerves and the subclavian vessels...
s, pelvic fracture
Pelvic fracture
Pelvic fracture is a disruption of the bony structure of the pelvis, including the hip bone, sacrum and coccyx. The most common cause in elderly is a fall, but the most significant fractures involve high-energy forces such as a motor vehicle accident, cycling accidents, or a fall from significant...
s, leg and arm fractures
Bone fracture
A bone fracture is a medical condition in which there is a break in the continuity of the bone...
, cuts in the skin
Wound
A wound is a type of injury in which skin is torn, cut or punctured , or where blunt force trauma causes a contusion . In pathology, it specifically refers to a sharp injury which damages the dermis of the skin.-Open:...
and soft tissue. Some have blood in the brain
Intracranial pressure
Intracranial pressure is the pressure inside the skull and thus in the brain tissue and cerebrospinal fluid . The body has various mechanisms by which it keeps the ICP stable, with CSF pressures varying by about 1 mmHg in normal adults through shifts in production and absorption of CSF...
."
The Los Angeles County Coroner
Los Angeles County Coroner
The Los Angeles County Department of Coroner was created in its present form in Boyle Heights on December 7, 1990 by an ordinance approved by the Los Angeles County Board of Supervisors, though it has existed in some form since the late 19th century....
set up an air-conditioned tent that functioned as a temporary morgue at the site. One off-duty Los Angeles Police Department
Los Angeles Police Department
The Los Angeles Police Department is the police department of the city of Los Angeles, California. With just under 10,000 officers and more than 3,000 civilian staff, covering an area of with a population of more than 4.1 million people, it is the third largest local law enforcement agency in...
officer was among the confirmed deaths, as was the Metrolink train's engineer,
an employee of Veolia Transportation, a contracted operator of Metrolink.
One of the passengers who died was a survivor of the 2005 Glendale train crash.
Another had been commuting by train since Metrolink's inception in 1992.
Many victims were residents of suburban Simi Valley and Moorpark on their way home from work in the Los Angeles area.
The four other crew members of the two trains survived.
The conductor and engineer of the freight train were trapped inside the lead locomotive while it was engulfed in flames; the firefighters who rescued the pair found them banging on the thick glass windshield, unable to escape. The freight crew also had a brakeman
Brakeman
A brakeman is a rail transport worker whose original job it was to assist the braking of a train by applying brakes on individual wagons. The advent of through brakes on trains made this role redundant, although the name lives on in the United States where brakemen carry out a variety of functions...
riding in the second locomotive who was injured in the crash.
The search for victims came to an end shortly after 14:30 PDT on September 13, approximately 22 hours after the collision.
Service disruptions
The crash disrupted service on the Pacific SurflinerPacific Surfliner
The Pacific Surfliner is a Amtrak regional passenger train route serving communities on the coast of Southern California between San Diego and San Luis Obispo....
and the Coast Starlight
Coast Starlight
The Coast Starlight is a passenger train operated by Amtrak on the West Coast of the United States. It runs from King Street Station in Seattle, Washington, to Union Station in Los Angeles, California. The train's name was formed as a merging of two of Southern Pacific's train names, the Coast...
. Amtrak
Amtrak
The National Railroad Passenger Corporation, doing business as Amtrak , is a government-owned corporation that was organized on May 1, 1971, to provide intercity passenger train service in the United States. "Amtrak" is a portmanteau of the words "America" and "track". It is headquartered at Union...
canceled service on the Pacific Surfliner between San Luis Obispo
San Luis Obispo (Amtrak station)
The San Luis Obispo Amtrak Station is an Amtrak rail station in the city of San Luis Obispo, California. It is the northern terminus of Amtrak's Pacific Surfliner from San Luis Obispo to San Diego and it also serves the Coast Starlight from Seattle, Washington to Los Angeles, California...
and Union Station in Los Angeles and Thruway Motorcoach buses transported Coast Starlight passengers from Union Station to Santa Barbara
Santa Barbara (Amtrak station)
The Santa Barbara Train Station, sometimes referred to as the Santa Barbara Amtrak Station, is the passenger rail station in Santa Barbara, California. It is served by two Amtrak lines, the Coast Starlight and the Pacific Surfliner. The Coast Starlight runs once daily in each direction between...
to board the trains. Metrolink service on the Ventura County Line was interrupted north of Chatsworth, and all service resumed four days after the accident.
Preliminary investigation controversy
Metrolink spokeswoman Denise Tyrrell disclosed the day after the crash that a preliminary investigation of dispatch records and computers showed the engineer of the Metrolink passenger train failed to stop his train for a red railway signalRailway signal
A signal is a mechanical or electrical device erected beside a railway line to pass information relating to the state of the line ahead to train/engine drivers. The driver interprets the signal's indication and acts accordingly...
, which indicated his train did not have permission to proceed. She was quoted as saying, "We don't know how the error happened, but this is what we believe happened. We believe it was our engineer who failed to stop at the signal." Tyrrell said that if the engineer obeyed the signal, the accident would not have occurred. However Los Angeles County Supervisor
Los Angeles County Board of Supervisors
The Los Angeles County Board of Supervisors is the five-member nonpartisan governing board of Los Angeles County, California. Members of the board of supervisors are elected by district. They were as of December 2, 2008:*District 1: Gloria Molina...
and Metrolink board member Don Knabe
Don Knabe
Donald R. Knabe is a member of the Los Angeles County Board of Supervisors, serving the Fourth District. Knabe is the current Chairman for the 2010 session. He recently was reelected on the June 3, 2008 election....
said it was premature to blame the engineer, speculating that "there could always be a technical malfunction where... there was a green light both ways."
After a Metrolink board meeting two days after her remarks, Tyrrell resigned. Tyrrell stated that she quit because a Metrolink Board statement called her announcement premature, and inappropriate; she maintained that it was proper to get out in front of the story before the NTSB took over the investigation. She stated that she asked for and received authorization to make the comments from David Solow, Metrolink's chief executive. Solow confirmed that he did give authorization, but said in hindsight he would not have given permission. After her resignation, some good government
Good government
Good government is a normative description of how government is supposed to be constituted. It has been frequently employed by various political thinkers, ideologues and politicians.- Thomas Jefferson and Good government :...
proponents praised Tyrrell for her candor, including the chief public advocate with California Common Cause
Common Cause
Common Cause is a self-described nonpartisan, nonprofit lobby and advocacy organization. It was founded in 1970 by John W. Gardner, a Republican former cabinet secretary under Lyndon Johnson, as a "citizens' lobby" with a mission focused on making U.S. political institutions more open and...
. The Los Angeles Times
Los Angeles Times
The Los Angeles Times is a daily newspaper published in Los Angeles, California, since 1881. It was the second-largest metropolitan newspaper in circulation in the United States in 2008 and the fourth most widely distributed newspaper in the country....
also published an editoral by columnist Patt Morrison
Patt Morrison
Patt Morrison is a journalist, author, and radio—television personality based in Los Angeles and Southern California.-Media:Morrison is a writer for the Los Angeles Times, with the weekly 'Patt Morrison Asks' column, and received the Joseph M. Quinn award in 2000 from the Los Angeles Press Club...
sympathetic to Tyrrell's position, in which she says, "I am unclear of the concept of how the truth can somehow be premature. The truth is the truth."
Official investigation
The NTSB led the official investigation to determine the probable cause, but NTSB officials had not commented on the accident prior to the Metrolink statement. In a subsequent press conference at the scene two hours after Tyrrell's comments, an NTSB official cautioned that the cause of the accident is still under investigation. The NTSB studied the data from the train event recorders, which had been recovered by NTSB investigators working at the scene. The Metrolink train had two data recorders, one badly damaged, and the freight train had a data and a video recorder. The NTSB said it would collect other evidence and interview witnesses to try to officially report within a year's time why the crash occurred.Tests of the railway signal system after the accident showed it was working properly, and should have shown proper signal indications to the Metrolink train, with two yellow signals as the train approached the Chatsworth station, and a red signal at the switch north of the station. "We can say with confidence that the signal system was working," the lead NTSB board member stated at a news conference after the tests. This focused the NTSB investigation on human factors
Human factors
Human factors science or human factors technologies is a multidisciplinary field incorporating contributions from psychology, engineering, industrial design, statistics, operations research and anthropometry...
.
Before releasing the accident scene and allowing restoration of service, the NTSB also conducted a final sight distance
Stopping sight distance
Stopping sight distance is a term used in highway design. It is defined as "the length of roadway ahead visible to the driver."-Sight distance:...
test. An identical Metrolink train and pair of Union Pacific locomotives were brought together at the point of impact and slowly backed away from each other. The test showed that the trains' engineers could not see each other until less than five seconds before the collision.
The surviving crew members could not be interviewed by the NTSB immediately after the accident because they were still recovering from their injuries. The NTSB was able to interview the Metrolink conductor about recorded radio communications, which did not capture the required communication between the conductor and engineer on the aspects displayed by the last two signals the train passed before the accident. He confirmed they did not call out the last two signals.
The NTSB also stated that a railroad switch
Railroad switch
A railroad switch, turnout or [set of] points is a mechanical installation enabling railway trains to be guided from one track to another at a railway junction....
showed evidence of damage consistent with the Metrolink passenger train "running through" the trailing switch points while they were set to allow the freight train to proceed onto the adjacent track, forcing them out of the way. "The switch bars were bent like a banana. It should be perfectly straight," according to the NTSB official. The NTSB member in charge of the investigative team said they were also concerned with possible fatigue issues related to the engineer's split shift
Split shift
Split shift is an employment schedule, a type of shift work where a person's normal work day is split into two or more segments; for example a person may work from 5 a.m. to 9 a.m. and then have a break until 3 p.m. at which point he might return to work until 7 p.m...
. The engineer worked an 11.5-hour shift split with a 3.5-hour break, leaving only nine hours away from work between workdays.
The Federal Railroad Administration
Federal Railroad Administration
The Federal Railroad Administration is an agency in the United States Department of Transportation. The agency was created by the Department of Transportation Act of 1966...
(FRA) is also investigating to determine if any federal safety regulations were violated. The California Public Utilities Commission
California Public Utilities Commission
The California Public Utilities Commission is a regulatory agency which regulates privately owned public utilities in the state of California, including electric power, telecommunications, natural gas and water companies...
, the state agency responsible for regulating railroads, also reported that it has ten investigators with railroad experience working in conjunction with the NTSB, and will also be looking into the matter of the Tyrrell resignation.
Possible false green
Before the conclusion of the formal investigation, three witnesses came forward to say that they observed the signal to be green as the Metrolink train departed the Chatsworth station just before the collision. A newspaper reporter interviewed the witnesses at the station, and confirmed that the signal was visible from the station, and that the witnesses could correctly identify the colors displayed. A safety consultant said that although this type of signal failure is extremely rare, he had seen it twice before in his 13-year career as a locomotive engineer. The NTSB considered the eyewitness' accounts and, based on the results of its tests of the signal system and on the distance between the witnesses and the signal, rejected them as "contrary to the other evidence".
Text messaging
Text messaging
Text messaging, or texting, refers to the exchange of brief written text messages between fixed-line phone or mobile phone and fixed or portable devices over a network...
with a teenage train enthusiast
Railfan
A railfan or rail buff , railway enthusiast or railway buff , or trainspotter , is a person interested in a recreational capacity in rail transport...
while operating the train, a violation of Metrolink rules according to the agency. The last message received from the engineer, time-stamped one minute before the collision, reportedly said, "yea ... usually @ north camarillo," apparently a reference to a town further down the line where the engineer expected to meet another train.
The NTSB did not recover the engineer's cellphone in the wreckage and said the teenagers were cooperating with the investigation, initially noting that similar rumors about an engineer using a cell phone from an investigation recently conducted in Boston were unfounded. After receiving the engineer's cell phone records under subpoena, the NTSB confirmed that engineer was texting while on duty, but had not yet correlated the messages with the accident timeline. After completing a preliminary timeline, the NTSB placed the last text message sent by the engineer at 22 seconds before impact.
An NTSB representative refused to comment further on the preliminary timeline, which investigators were still refining. Two University of Southern California academics used the information in the NTSB statement to determine that the last text message sent by the Metrolink train's engineer would have been sent a few seconds after he had passed the last red signal. This would make unconsciousness
Unconsciousness
Unconsciousness is the condition of being not conscious—in a mental state that involves complete or near-complete lack of responsiveness to people and other environmental stimuli. Being in a comatose state or coma is a type of unconsciousness. Fainting due to a drop in blood pressure and a...
an unlikely cause for this error, since the engineer was able to compose and send the message; instead a psychology professor from the University of Utah
University of Utah
The University of Utah, also known as the U or the U of U, is a public, coeducational research university in Salt Lake City, Utah, United States. The university was established in 1850 as the University of Deseret by the General Assembly of the provisional State of Deseret, making it Utah's oldest...
raised the possibility that "inattention blindness" caused the engineer to fail to see the signal.
The day after the NTSB confirmed the engineer was texting, and less than one week after the accident, the California Public Utilities Commission unanimously passed an emergency order to temporarily ban the use of cellular communication devices by train crew members, citing this accident and a previous San Francisco Municipal Railway
San Francisco Municipal Railway
The San Francisco Municipal Railway is the public transit system for the city and county of San Francisco, California. In 2006, it served with an operating budget of about $700 million...
accident where the train operator was using a cell phone.
A week later, texting while driving
Texting while driving
Texting while driving is the act of composing, sending, reading text messages, email, or making other similar use of the web on a mobile phone while operating a motor vehicle. The practice has been viewed by many people and authorities as dangerous. It has also been ruled as the cause of some motor...
an automobile was outlawed in California, effective January 1, 2009.
There was no federal regulation prohibiting cell phone use by train crews at the time of the accident, but the NTSB had recommended the Federal Railroad Administration address the issue in 2003, after concluding cell phone use by a freight train engineer contributed to a fatal head-on train collision in Texas
Texas
Texas is the second largest U.S. state by both area and population, and the largest state by area in the contiguous United States.The name, based on the Caddo word "Tejas" meaning "friends" or "allies", was applied by the Spanish to the Caddo themselves and to the region of their settlement in...
in 2002. However, 19 days after the accident the FRA administrator issued Emergency Order No. 26 restricting the use of "personal electronic or electrical devices" by railroad operating employees.
On March 3, 2009 federal investigators released records showing that the train engineer Robert M. Sanchez had allowed a train enthusiast to ride in the cab several days before the crash, and that he was planning to let him run the train between four stations on the evening of the crash. "I'm gonna do all the radio talkin' ... ur [sic] gonna run the locomotive & I'm gonna tell u [sic] how to do it," Sanchez wrote in one text. Records also show Sanchez had received two prior warnings from his supervisors about improper use of cellphones while in the control cab.
Conductor's role
The operating rules for trains with a sole engineer is that all signals are to be reported to the conductor. This allows the conductor to pull the tailPulled tail
Pulled tail is the act of a guard or conductor of a railway to apply the emergency brakes where something untoward has been noticed. This could be an excess of speed in a section of line known to have a lower speed, or strange noises and shaking that might indicate that the train has derailed or...
(apply the brakes) should the engineer appear to be incapacitated for any reason. However, in this incident, according to the data video, the last two signals were not reported, nor did the conductor apply the brakes.
Unusually, the conductor told the engineer that the starting signal was green, rather than the other way around.
NTSB's conclusions and recommendations
On January 21, 2010, the NTSB issued a press release announcing its conclusions from the investigation into the collision. In the report, the NTSB concluded that the cause of the accident was most likely the result of the Metrolink engineer's use of text messaging while on duty, which led to the train being operated through a red signalSignal passed at danger
A Signal passed at danger , in British railway terminology, occurs when a train passes a stop signal without authority to do so. It is a term primarily used within the British Railway Industry, although it can be applied worldwide.-Categories of SPAD:...
into the path of the oncoming Union Pacific freight train. The investigation has led the NTSB to recommend that the federal government require the installation of video and audio recording equipment to be installed in all locomotive and train operating cabs.
Positive train control
Officials, experts, and litigators have injected the example of this accident into the discussions around deployment of positive train controlPositive Train Control
Positive train control is a system of monitoring and controlling train movements to provide increased safety.-Overview:The main concept in PTC is that the train receives information about its location and where it is allowed to safely travel, also known as movement authorities...
(PTC), a safety backup system that can automatically stop a train. Federal Railroad Administrator Joseph H. Boardman
Joseph H. Boardman
Joseph H. Boardman is the president of Amtrak and formerly Administrator of the United States Federal Railroad Administration.He was nominated by President George W. Bush on March 17, 2005 and confirmed by the United States Senate on April 28, 2005. He was the eleventh Federal Railroad...
told a reporter days after the accident that PTC "would have stopped the train before there was a collision." The National Transportation Safety Board (NTSB) member leading the investigation also said she was convinced that such a system "would have prevented this accident." These systems are not widely deployed yet, and would require a multi-billion US dollar investment to reach that goal nationwide. A Metrolink board member acknowledged they were studying this technology, but said that press reports implying that PTC systems were available off the shelf
Commercial off-the-shelf
In the United States, Commercially available Off-The-Shelf is a Federal Acquisition Regulation term defining a nondevelopmental item of supply that is both commercial and sold in substantial quantities in the commercial marketplace, and that can be procured or utilized under government contract...
are misleading, and denied that cost was the primary reason it has not been deployed there. PTC has been on the NTSB's most wanted safety improvements list since 2001.
At the next regularly scheduled Metrolink board meeting after the accident, the board decided not to wait for PTC to be ready for deployment before making system safety improvements; instead Metrolink will expand the existing automated train stop system used on 30 miles (48.3 km) of Metrolink track in Orange County
Orange County, California
Orange County is a county in the U.S. state of California. Its county seat is Santa Ana. As of the 2010 census, its population was 3,010,232, up from 2,846,293 at the 2000 census, making it the third most populous county in California, behind Los Angeles County and San Diego County...
across its 350 miles (563.3 km) system. Metrolink's automated train stop system will automatically apply the brakes to stop a train if the engineer fails to respond to a warning within eight seconds. It was originally installed in the 1950s by the Atchison, Topeka and Santa Fe Railway
Atchison, Topeka and Santa Fe Railway
The Atchison, Topeka and Santa Fe Railway , often abbreviated as Santa Fe, was one of the larger railroads in the United States. The company was first chartered in February 1859...
to allow trains to operate at speeds of over 79 mph under regulations imposed by the Interstate Commerce Commission
Interstate Commerce Commission
The Interstate Commerce Commission was a regulatory body in the United States created by the Interstate Commerce Act of 1887. The agency's original purpose was to regulate railroads to ensure fair rates, to eliminate rate discrimination, and to regulate other aspects of common carriers, including...
, a former federal regulatory body whose safety functions have since been assumed by the Federal Railroad Administration
Federal Railroad Administration
The Federal Railroad Administration is an agency in the United States Department of Transportation. The agency was created by the Department of Transportation Act of 1966...
. Metrolink is also adding a second engineer to some trains to improve safety.
Litigation
On September 15, 2008, the family of a 19-year-old killed in the crash announced they had filed a claim with Metrolink, generally a precursor to a lawsuit, "alleging the agency chose not to use the available rail safety features," referring to positive train control which they say would have averted the disaster. Eleven days later, an attorney representing the brakeman of the freight train announced a lawsuit against Metrolink, which also named Veolia Transportation and its subsidiary, Connex Railroad, the Metrolink engineer's employer, as defendants. The claim they filed against Metrolink and Veolia was denied, allowing them to proceed with the lawsuit. The lawyer asserted that the Metrolink engineer "was asleep at the switch and not paying attention to what was going on around him..." and that Metrolink "allowed a dangerous, defective and unsafe condition to exist."An issue likely to come into play will be a provision in the Amtrak Reform and Accountability Act of 1997 (P.L. 105-134), which places a US$
United States dollar
The United States dollar , also referred to as the American dollar, is the official currency of the United States of America. It is divided into 100 smaller units called cents or pennies....
200 million cap on the aggregate of all passengers' damage claims in a railroad accident against a passenger railroad, including punitive damages. Bloomberg News
Bloomberg L.P.
Bloomberg L.P. is an American privately held financial software, media, and data company. Bloomberg makes up one third of the $16 billion global financial data market with estimated revenue of $6.9 billion. Bloomberg L.P...
reported that this event would likely be the first legal test of this law, according to a former House rail committee
United States House Transportation Subcommittee on Railroads, Pipelines, and Hazardous Materials
The Subcommittee on Railroads, Pipelines, and Hazardous Materials is a subcommittee within the House Transportation and Infrastructure Committee...
staffer who helped write the law, who predicted that given the number of casualties, the cap is almost certainly going to be an issue in pending litigation. An attorney representing two of the victims agreed, saying payouts could range from $5 million to $10 million per death or serious injury. Metrolink reportedly has insurance coverage totaling $150 million.
The California Government Claims Act prescribes a six-month deadline for initiating claims for personal injury or wrongful death against government agencies after an accident, so time was of the essence for plaintiffs as well as their legal advocates. However, the aggressive tactics of some lawyers led the State Bar of California
State Bar of California
The State Bar of California is California's official bar association. It is responsible for managing the admission of lawyers to the practice of law, investigating complaints of professional misconduct, and prescribing appropriate discipline...
to publicly warn its members that unsolicited contact with a potential client is both illegal and unethical.
Other railroads
In response to this event, other commuter railroads made statements to reassure their passengers of the safety of their operations, and these responses provided some perspective on how other operators mitigate related risks. A spokesman for the nation's largest commuter rail operation, the Long Island Rail RoadLong Island Rail Road
The Long Island Rail Road or LIRR is a commuter rail system serving the length of Long Island, New York. It is the busiest commuter railroad in North America, serving about 81.5 million passengers each year. Established in 1834 and having operated continuously since then, it is the oldest US...
in New York
New York
New York is a state in the Northeastern region of the United States. It is the nation's third most populous state. New York is bordered by New Jersey and Pennsylvania to the south, and by Connecticut, Massachusetts and Vermont to the east...
, said that it had studied positive train control
Positive Train Control
Positive train control is a system of monitoring and controlling train movements to provide increased safety.-Overview:The main concept in PTC is that the train receives information about its location and where it is allowed to safely travel, also known as movement authorities...
, but decided to stick with its "automatic speed control system," a form of cab signaling with automatic train stop
Automatic Train Stop
An automatic train stop is a system on a train that will automatically stop a train if certain situations happened to prevent accidents from happening....
using technology that is more than 50 years old. The San Diego
San Diego, California
San Diego is the eighth-largest city in the United States and second-largest city in California. The city is located on the coast of the Pacific Ocean in Southern California, immediately adjacent to the Mexican border. The birthplace of California, San Diego is known for its mild year-round...
's Coaster commuter line also has an automatic train stop system that a spokesman said will stop the train automatically if the engineer fails to stop at a red stop signal.
Boston's MBTA
Massachusetts Bay Transportation Authority
The Massachusetts Bay Transportation Authority, often referred to as the MBTA or simply The T, is the public operator of most bus, subway, commuter rail and ferry systems in the greater Boston, Massachusetts, area. Officially a "body politic and corporate, and a political subdivision" of the...
says its "Cab Signal with Positive Stop" system can stop a train that passes a stop signal or when another train is in its path; the system averted disaster in March 2008 when it stopped a train heading for a runaway freight car. The Southeastern Pennsylvania Transportation Authority had Automatic Train Control
Automatic Train Control
Automatic Train Control is a train protection system for railways, ensuring the safe and smooth operation of trains on ATC-enabled lines. Its main advantages include making possible the use of cab signalling instead of track-side signals and the use of smooth deceleration patterns in lieu of the...
on 80% of its system, and was planning to install it in the other 20% by 2014.
The Denver
Denver, Colorado
The City and County of Denver is the capital and the most populous city of the U.S. state of Colorado. Denver is a consolidated city-county, located in the South Platte River Valley on the western edge of the High Plains just east of the Front Range of the Rocky Mountains...
area Regional Transportation District
Regional Transportation District
The Regional Transportation District, or RTD, was organized in 1969 and is the regional authority operating public transit services in eight of the twelve counties in the Denver-Aurora-Boulder Combined Statistical Area in Colorado. RTD is governed by a 15-member, publicly elected Board of...
said that its FasTracks
FasTracks
FasTracks is a twelve-year, $6.5 billion public transportation expansion plan for the Denver-Aurora and Boulder metropolitan areas in Colorado, USA, developed by the Regional Transportation District...
commuter rail program has been designed to limit exposure to freight traffic by using physical separation with separate freight and passenger tracks where possible and using temporal separation by running passenger trains during the day, and freight at night and between rush hours. The San Jose Mercury News
San Jose Mercury News
The San Jose Mercury News is a daily newspaper in San Jose, California. On its web site, however, it calls itself Silicon Valley Mercury News. The paper is owned by MediaNews Group...
reported that San Francisco Bay Area
San Francisco Bay Area
The San Francisco Bay Area, commonly known as the Bay Area, is a populated region that surrounds the San Francisco and San Pablo estuaries in Northern California. The region encompasses metropolitan areas of San Francisco, Oakland, and San Jose, along with smaller urban and rural areas...
Caltrain
Caltrain
Caltrain is a California commuter rail line on the San Francisco Peninsula and in the Santa Clara Valley in the United States. The northern terminus of the rail line is in San Francisco, at 4th and King streets; its southern terminus is in Gilroy...
commuters are much less likely to be in a head-on collision because opposing trains usually run on separate tracks, and runs freight only at night on a large portion of its route. The North County Transit District
North County Transit District
The North County Transit District is the agency responsible for public transportation in North San Diego County, California, United States...
's spokesman for its Sprinter service in San Diego also said it runs freight only at night when passenger service is suspended.
Memorials
Following the collision a temporary, spontaneous memorial of flowers and notes was erected at the Simi Valley Amtrak/Metrolink StationSimi Valley (Amtrak station)
The Simi Valley Amtrak/Metrolink Station is an Amtrak and Metrolink rail station in the city of Simi Valley. It is served by Amtrak's Pacific Surfliner from San Luis Obispo to San Diego, Amtrak's Coast Starlight from Los Angeles Union Station to Seattle, and Metrolink's Ventura County Line from Los...
. On September 8, 2009, the first permanent memorial, a plaque, was placed in Union Station
Union Station (Los Angeles)
Los Angeles Union Station is the main railway station in Los Angeles, California. The station has rail services by Amtrak and Amtrak California and Metrolink; light rail/subways are the Metro Rail Red Line, Purple Line, Gold Line. Bus rapid transport runs on the Silver Line...
. The Metrolink Memorial Plaza was dedicated on September 12, 2009 at the Simi Valley station. The plaza features 11 columns, one each for the ten deceased passengers from Simi Valley and an additional one for the 14 other deceased victims. There are also 25 markers on the grounds to commemorate each victim as well as a seating area and a plaque in remembrance to the 2005 Glendale train crash. Two days later, on the one-year anniversary of the crash a memorial ceremony was held at Stony Point Park, near the location of the collision.
See also
- 1987 Maryland train collision – a similar accident in 1987 that led to automatic train stop installation in freight locomotives
- 2005 Glendale train crash – the second deadliest Metrolink accident
- Hinton train collisionHinton train collisionThe Hinton train collision was a railway accident that occurred on February 8, 1986. Twenty-three people were killed in a collision between a Canadian National Railway freight train and a Via Rail passenger train. It was the most lethal Canadian rail disaster since the Dugald accident of 1947...
– a similar accident that occurred in 1986 in Canada - June 2009 Washington Metro train collision - deadliest Washington MetroWashington MetroThe Washington Metro, commonly called Metro, and unofficially Metrorail, is the rapid transit system in Washington, D.C., United States, and its surrounding suburbs. It is administered by the Washington Metropolitan Area Transit Authority , which also operates Metrobus service under the Metro name...
accident
External links
- Audio and video from KNX 1070 AM
- Brief Overview of the Head-On Collision Between Metrolink Train 111 and a Union Pacific Freight Train, September 12, 2008, California Public Utilities Commission
- List of victims from the Los Angeles Times
- Los Angeles Times full coverage page
- Gallery from KABC-TV
- Gallery from the Los Angeles Times
- Gallery from Traverse Legal, PLC
- NTSB report