An Amtrak engineer mistakenly drove a Capitol Corridor train at nearly twice the allowed speed through a track switch near Davis in December, causing the train to jerk violently, injuring five occupants, according to documents obtained by The Sacramento Bee through the federal Freedom of Information Act.
Amtrak has declined to discuss the incident, which involved a train heading west from Sacramento to Davis at 7:10 a.m. on Dec. 7, despite repeated requests since December. The agency instead sent The Bee a brief email statement late Monday saying an investigation found “human error” and added that the “train crew’s performance has been addressed.”
The Amtrak reports obtained by The Bee reveal the engineer took the train at 78 miles per hour into a track switch that had a 40 mph speed limit. Train crew members, in written statements, described a dramatic few seconds aboard the #527 train as cars jolted one way then the other, tossing passengers, bags and coffees around.
The Amtrak incident report, filed in January, concluded a “speed violation” had occurred, and determined that the engineer “lost situational awareness” and “did not recognize the action to be taken.” The engineer’s name was redacted from those reports.
The document notes that another train crew member, whose name and job title were redacted, “failed to recognize that it was their responsibility to take action when (redacted) did not.” It also makes brief note that inadequate supervision, substandard communication, and substandard mental or physical conditions played a role in the errors that led to the incident, but does not elaborate.
According to the incident report, the train passed a track signal indicating that the switch ahead was open and that the adjacent track was clear. “This signal requires the train to proceed on diverging route not exceeding prescribed speed through turnout. The maximum authorized speed through the turnout is 40 mph. Train 527 entered the diverging route at approximately 78 mph. The engineer was operating from the lead end of the move.”
Federal records show five people were injured – four passengers and one crew member. All injuries appeared to be minor. One woman suffered a broken thumb.
Though injuries were mild, several passengers say the train rocked back and forth so dramatically they thought it was going to derail. One woman said she screamed, thinking she might die. One said a crew member later told passengers she thought the train was going to “eat dirt.”
Three train crew members wrote brief statements describing the moments the train’s five cars hit the track switch in succession.
“As we (crossed over) from (track one to two), I heard a loud bang,” one wrote. “I could see the café car leaning about 40 degrees to the right. I shouted everyone ‘sit down,’ then our car hit and rocked hard to the right then back to the left hard. People and objects were tossed about.”
Another wrote, “Passengers were thrown around in the cars – coffees and bags flying through the car.”
After the train righted itself, crews inspected the train in Davis, then it continued until arriving in Martinez. There, the passenger with the broken thumb was transported via ambulance to a hospital.
The train was removed from service and crew members were taken for drug and alcohol testing. The incident report notes that employee discipline assessments were “submitted,” but it does not say whether employees were in fact disciplined.
Federal Railroad Administration spokeswoman Desiree French said her agency initially looked into the incident, but left it up to Amtrak to conduct the analysis.
“FRA’s investigator determined the Amtrak incident on the Capitol Corridor did not meet the threshold for a full investigation, and (Amtrak) was instructed to provide an incident report,” French said in an email to The Bee.
Several passengers contacted by The Bee expressed anger that Amtrak has not offered a full public explanation of what happened, how it occurred and what steps, if any, Amtrak has taken to reduce the chance of similar incidents.
“It’s incensing that a corporation receiving ... tax-funded grants annually is refusing transparency on what could have been a catastrophic incident,” said one of the passengers that day, Matt Williams.
Ron Goldman, a Los Angeles attorney and critic of railroad safety efforts, contends the rail agency owes it to riders to tell them what happened.
“The public is not an adversary,” he said. “The public is an interested party that has the right and the need to know what is going on. It is the public that suffers the loss when things are not properly maintained or operated.”
Although the train did not derail, Goldman said “the difference between a minor issue and a major calamity can be a matter of a fraction of an inch or a half of a mile per hour. These things are very dangerous. You can’t measure safety by saying we escaped, or the train arrived.”
The Federal Railroad Administration incident database shows only a handful of speed-related crashes annually. But speed-related derailments have ended in deaths in recent years.
A 2012 crash in Canada killed three engineers and injured dozens of passengers when the train failed to slow at a track switch, despite signals to do so. Eight people were killed and 200 injured during a Philadelphia derailment in 2015 when an Amtrak train went into a 50 mph curve at 106 mph.
The National Transportation Safety Board concluded the Philadelphia crash likely would not have occurred if the train had been equipped with a computer-based automatic braking system known as Positive Train Control, or PTC. Similarly, UP officials told The Bee that they believe PTC would have averted the December Amtrak jolt near Davis because the computer would have taken control of the train when the engineer failed to slow it.
Amtrak, UP and other train operators are under federal mandate to have PTC installed by the end of 2018.
The train involved in the December jolt outside of Davis was one of several daily Capitol Corridor trains, operated by Amtrak, that run between Sacramento and the Bay Area. Although operated by Amtrak, the Capitol Corridor system is also overseen by a board of officials from local cities and counties.
Capitol Corridor chief David Kutrosky said he received the same email statement from Amtrak that was sent to the Bee, and has forwarded it to his board. He said an Amtrak official also told him Amtrak has ordered train engineers and conductors to step up their onboard communications as their trains pass signals.
“Knock on wood, we have had no incidents since then,” Kutrosky said.