Friday, February 17, 2017

NTSB Final Report on the 2015 Metrolink Oxnard Collision Omits Elements of "Probable Cause"


The Los Angeles Times edition featuring the deadly Oxnard Metrolink Collision of February 24, 2015 - Click for larger image (http://jamesmcgillis.com)

NTSB Final Report on the 2015 Metrolink Oxnard Collision Omits Elements of "Probable Cause"

From the National Transportation Safety Board - Highway Accident Brief (Final Report), dated December 15, 2016:

“On Tuesday, February 24, 2015, in the predawn hours, Metrolink commuter train No. 102, operated by Amtrak, was en route from Oxnard, in Ventura County, California, to Los Angeles. As the train approached the South Rice Avenue grade crossing (near Oxnard) about 5:44 a.m., it collided with a 2005 Ford F450 service truck towing a two-axle utility trailer.”

The Metrolink cabcar in which Senior Engineer Glenn Steele and a student engineer were riding at the time of the deadly collision in February 2015 - Click for larger image (http://jamesmcgillis.com)Probable Cause (According to the NTSB):

“The National Transportation Safety Board determines that the probable cause of the Oxnard, California, crash was the truck driver mistakenly turning onto the railroad right-of-way due to acute fatigue and unfamiliarity with the area.

The NTSB does not assign fault or blame for an accident or incident (probable cause only); rather, as specified by NTSB regulation, accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties… and are not conducted for the purpose of determining the rights or liabilities of any person.”


Having studied the Oxnard Metrolink collision of February 24, 2015 since its occurrence, I felt that the conclusions of NTSB Final Report omitted key facts. After analysis and reconstruction of the events leading up to the Metrolink Oxnard, my conclusions regarding the probable causes of the accident are as follows:

Memorial crosses attest to previous fatalities at the Fifth Street and Rice Avenue grade crossing where Metrolink Senior Engineer Glenn Steele lost his life - Click for larger image (http://jamesmcgillis.com)1. An inattentive and sleep-deprived utility truck driver turned his rig on to the tracks, leading to the collision.
2. An inattentive and sleep-deprived train crew failed to see or respond to lights on or near the tracks in sufficient time to stop the train.
3. Train Number 102 contained one older coach that did not incorporate current crash energy management (CEM) systems, leading to catastrophic failure of both its couplers.
4. The highway grade crossing had experienced twenty-one prior accidents, including one in which a driver had turned on to the tracks, resulting in a train collision.


Following is the official NTSB document list:

1. NTSB Launches Go-Team to Grade Crossing Accident in Oxnard, CA (February 24, 2015)
2. Preliminary Report Highway HWY15MH006, Executive Summary (March 19, 2015)
3. NTSB Opens Docket for 2015 Metrolink Accident (August 29, 2016)
4. National Transportation Safety Board (NTSB) “Final Report” on the 2015 Oxnard Metrolink Accident: Train and Truck Crash on Railroad Right-of-Way and Subsequent Fire (December 15, 2016)  PDF File

Beginning in April 2015, I published a series of blog articles that directly addressed or touched upon the February 24, 2015 Oxnard Metrolink collision. In chronological order, they are:

The poorly marked and poorly maintained grade crossing at Fifth Street and Rice Avenue where the fatal Metrolink collision occurred in February 2015 - Click for larger image (http://jamesmcgillis.com)1.  Metrolink Oxnard Train Collision Report - April 29, 2015
2.  Deadly Crude Oil Trains Coming Soon - April 30, 2015
3.  Metrolink Train Crash, A Personal Story - June 30, 2015
4.  5th & Rice - A Deadly Railroad Crossing - July 23, 2015
5.  The Glenn Steele Memorial Overpass - July 24, 2015
6.  Metrolink to Spend $338 Million - September 2, 2015
7.  Metrolink Anti-Derailment Blade Failure - Sept. 6, 2015
8.  BNSF Locomotives on Metrolink Trains - October 1, 2015
9.  "Google Pop Car" - Rail Safety Plan - Nov. 18, 2015
10. Ventura County Rail Deaths Scandal - Dec. 4, 2015
11. Agencies Ignore Rail Safety Issues - March 16, 2016
12. Metrolink Ignores Mismatched Brakes - March 25, 2016
13. Ventura County, CA - Rail Safety 2016 - April 11, 2016
14. Ventura County - Deadly Rail Collision - May 2, 2016
15. It's Time to Audit Metrolink Operations - May 15, 2016
16. Metrolink - Meager Track Maintenance - July 6, 2016


The mechanical couplers on the old Bombardier coach (right) were a mismatch to the Rotem coach (left), resulting in complete failure of both Bombardier couplers in the February 2015 Oxnard Metrolink collision - Click for larger image (http://jamesmcgillis.com)To supplement the sixteen articles listed above, I also created a website at, www.5thandRice.com.. It compiles several of the articles listed above. The intent of the website is to highlight the dangers at the intersection and grade crossing at Fifth Street and Rice Avenue, Oxnard, California. That is where the deadly 2015 Metrolink collision took place.

How did I arrive at my own findings of probable cause?

First, I reviewed all official NTSB documents, including the 163 support documents released on August 29, 2016. Since the NTSB Final Report found that the utility truck driver embodied all probable causes of the Oxnard accident, I bypassed that evidence. Beyond the issues with the driver, Jose Sanchez Ramirez, I searched for other factors contributing to the actual collision.

My Final Report” uses the NTSB Final Report as its basis. First, I stripped out most of the information regarding the driver. Then, I filled in the blanks in the NTSB Final Report, inserting relevant text from other NTSB documents. My personal notes and comments are in red typeface. My intent was to create a narrative, using only public records as my source. In reorganizing the evidence, I begin with Precrash Events, and then move on to Crash and Postcrash Events. They are as follows:

As of December 2016, both the roadway and the markings at the Fifth Street and Rice Avenue grade crossing had deteriorated to a condition worse than when the Oxnard Metrolink collision occurred in February 2015 - Click for larger image (http://jamesmcgillis.com)1. Truck Driver Activities (abbreviated)
2. Train Crew Activities (including student engineer interview)
3. Video File (a second-by-second recreation of the collision)
4. Train Wreckage (including documentation regarding the mismatched train set)
5. Railroad and Roadway Infrastructure (including postcrash infrastructure deterioration since the 2015 collision)

Since “My Final Report” draws from resources with widely varying formats, please accept my apologies for any formatting issues. If you read the full narrative, it becomes obvious that probable cause includes more than a utility truck driver making a wrong turn in the darkness. In order to determine “probable cause”, we must evaluate other factors. In order to understand how and why this avoidable accident happened, we need to evaluate the utility truck driver, the train crew, the mismatched train set and existing conditions at the highway grade crossing.