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AMTRAK Cascades Train Derailment, image, The lead locomotive car descended…

- - - - Employed by AMTRAK since 2004, held roles as a conductor, then became a certified engineer in 2013
      - Colleagues regard him as "competent, safe, and aware of his surroundings"
    - - Employed by AMTRAK in 2010, participated in training and became a qualified conductor in 2011
  - - - Diagnosed with obstructive sleep apnea, being treated with a CPAP machine
      - Type 2 Diabetes
      - Hypertension
      - High Cholesterol
    - - No health issues
- - - - Project was turned over for revenue before all control measures identified in a risk assessment were implemented
        
        Preliminary Hazard Analysis was not updated to reflect absence of designated hazard mitigation
      - Procedures and Training - protective mitigation strategy not implemented
    - - Overlooked by management of AMTRAK Pacific Northwest Division
  - - - Responsible to ensure project was 'safe to operate'
        
        No formalised approach by Washington State to oversee Sound Transit's implementation of Safety Certification process
        
        Term is ambiguous and does not give clear goal
        
        34 field and compliance inspections performed, none included safety certification in their investigation scope
- - - - 4,400 horsepower diesel-electric alternating current (AC) loco
      - Released from Siemens factory on 30th March 2017
      - Completed 5 revenue services prior to accident
    - - Manufactured in 1998
- - - - Other locomotives would sometimes sound an alarm before going into penalty, some had no alarm at all and went straight into penalty
        
        Engineer was unsure what the alarm was for when it activated, and did not take action
  - - - Was not covered during training
      - Had not experienced the alarm in the few times he had operated this model of locomotive before
  - - - 6 articulated connections failed, 5 fully detached and 1 partially detached
      - One fully detached collided with another rail car in which 3 passengers died
      - Grandfathered by the FRA in 1999, but AMTRAK petitioned to continue using the rail cars
        
        FRA set conditions for use, including maximum operating speed of 79mph
        
        FRA had concerns that higher energy events would be expected to experience lateral displacement & articulate connects would fail (as opposed to conventional equipment)
        
        Created greater hazard of secondary collisions
      - Known to be vulnerable to detachment based on previous incidents
      - No ability to anchor child protection capsules to rail car seats
    - - Roof deformed into operators compartment about 13 inches
      - Roof panels sheared off
      - Laminated glass prevented glass pieces shattering everywhere
      - Structural condition remained in tact
  - - - Contributed to injuries, prevented passengers from escaping
- - - - Could the low temperature and rain have caused the track to become slippery?
- - - - Sound Transit did not include MP 19.8 (where speed drops from 79mph to 30mph)
        
        Sound Transit said it should be Amtrak's responsibility to include it
        
        Sound Transit failed to apply same level of speed risk mitigation throughout the entire Lakewood subdivision
- - - - Failure to properly account for all personnel on site
      - Unnecessary dispatch of additional resources from a jurisdiction that was further away than a jurisdiction that was closer with available units
  - - - On day of accident: Air brake test - no exception
      - Minor electrical fault during sequence test to set up the locomotives
        
        Corrected by mechanical team, 9 minute delay as a result
    - - No major failures detected
  - - - Driver became unaware of his position on the route
    - - Signs not designed to stand out in their environment
- - - - Needed to be able to withstand 800,000 pounds of compressive strength applied to the coupler faces without permanently deforming the body structure
      - FRA enacted a final ruling to grandfather articulated train sets that no longer met the updated safety compliance requirements, but accepted petitions to delay this
    - - Contributed to passenger injuries as passengers were ejected through the open windows due to the force of the incident
  - - - Reduced life expectancy, increased risk of detachments
  - - - Bought my WSDOT to be used with Amtrak to service
  - - - Determined by commercial considerations & material fatigue considerations