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.”
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:
1. An inattentive and sleep-deprived utility truck driver turned his rig on to the tracks, leading to the collision.
2. Prior to the collision, the train crew did not recognize "fouling" of 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.
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:
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 - September 6, 2015
8. BNSF Locomotives on Metrolink Trains - October 1, 2015
9. "Google Pop Car" - Rail Safety Plan - November 18, 2015
10. Ventura County Rail Deaths Scandal - December 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
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:
1. Truck Driver Activities (abbreviated)
2. Train Crew Activities (including student engineer interview)
3. Video Transcript (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, train crew actions, the mismatched
train set and existing conditions at the highway grade crossing.
By James McGillis at 05:12 PM | Railroad Safety | Comments (0) | Link
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