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.

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By James McGillis at 05:12 PM | Railroad Safety | Comments (0) | Link

Inadequate Track Maintenance Puts Metrolink Passengers At Risk - 2016

 

Inadequate Track Maintenance Puts Metrolink Passengers At Risk

On June 24, 2016, I drove to the Metrolink Station in Chatsworth, California. My mission was to drop Carrie McCoy off for her Metrolink ride from Chatsworth to Los Angeles Union Station.

Since early 2016, all of the Metrolink trains that I have observed at the Chatsworth Station have been “double-enders”. By that, I mean there is a locomotive at each and of the train. On this occasion, the train arrived in Chatsworth with a locomotive at the “head end” and a Hyundai-Rotem cabcar at the trailing end.

In late 2015, as an interim safety measure, Metrolink instituted a second locomotive on each of its trains. The decision resulted from an equipment failure on a Hyundai-Rotem cabcar. In a February 2015 collision in Oxnard, California, the “pilot”, a debris-clearing blade at the front of a Metrolink cabcar, detached. As the pilot disappeared beneath the cabcar, it contributed to the derailment of the cabcar and several other Metrolink coaches. Because of that collision, thirty passengers were injured and Metrolink Senior Engineer Glenn Steele lost his life.

The locomotives that Metrolink leased to ride ahead of the Hyundai-Rotem cabcars are massive Burlington Northern Santa Fe (BNSF) freight locomotives.

Such locomotives normally pull heavy freight trains on long hauls. Before the Metrolink lease, nowhere in the country have such locomotives pushed or pulled passenger trains. Because of their size, weight and other factors, Metrolink has struggled to safely deploy their BNSF locomotives. A recent Los Angeles Times report indicated that many trains were still running without a locomotive at each end.

The original locomotive lease from BNSF was for one year. Even at that, Metrolink now operates them on a Federal Railroad Administration temporary waiver, not a permanent operating permit. By leasing the BNSF locomotives, Metrolink made a de facto admission that heading up a train with a Hyundai Rotem cabcar was inherently unsafe. If so, why is Metrolink still running trains headed up by Hyundai-Rotem cabcars?

While at the Chatsworth Station, I walked the platform from south to north. When viewing railroad tracks up close, I like to observe the condition of the infrastructure. Are any of the railroad ties rotten? Are many of the spikes loose? Are palm trees growing up between the rails? At Chatsworth, I found instances of all these deficiencies. Why does any of this matter?

If the Philips 66 Santa Maria Refinery has its way, several oil trains each day could pass through the Chatsworth Station on their way to Santa Barbara County. From the June 3, 2016 oil train derailment and fire near Mosier, Oregon, we now know that failure of even one bolt or rail anchor can lead to a catastrophe.

As I reached the north end of the platform, I stepped up some wooden stairs to better observe the tracks. As I looked down from there, I could see the milepost marker for that location stenciled on the side of the rail. It read “MP 445.4”, with an arrow pointing down to that exact location. In non-technical language, that means that it is 445.4 miles to the northern terminus of the Coast Line in San Francisco. In addition, that spot is where the wheel truck of an outbound Metrolink locomotive comes to rest at the Chatsworth Station.

As I looked more closely, I observed a broken rail anchor lying by the tracks at that exact location. After the Mosier, Oregon derailment, Union Pacific Railroad (UPRR) admitted that despite repeated visual inspections, specifically looking for deficiencies, inspectors missed badly corroded and rusted bolts. In the case of Chatsworth, the Southern California Regional Rail Authority (SCRRA), better known as Metrolink, owns and operates the double-track through Chatsworth Station.

Allowing rotten railroad ties, loose spikes and small palm trees to grow between the tracks at the Chatsworth Station is ample evidence that SCRRA is not properly inspecting or maintaining its own rail infrastructure. Allowing a broken or detached rail anchor to lie where a 432,000-pound BNSF locomotive comes to rest several times each day is inexcusable. Rather than relying on redundancy to save us all from its next derailment, SCRRA should inspect and repair its infrastructure in Chatsworth and throughout its railroad network.

Author’s Note: On July 8, 2016, just two days after the publication of this article, Metrolink announced the impending replacement of fifty-six failure-prone pilots on their Hyundai-Rotem cabcars. Although the recent lease of BNSF freight locomotives topped $20 million, Metrolink expects to replace the pilot blades for a mere $1.5 million. That would bring the cost of each replacement to $26,785. If the cost to replace the pilots is so low, why did Metrolink not explore that option from the outset?

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By James McGillis at 04:57 PM | Railroad Safety | Comments (1) | Link

As BNSF Freight Locomotives Fail The Test - It's Time to Audit Metrolink Operations - 2016

 

As BNSF Freight Locomotives Fail The Test - It's Time to Audit Metrolink Operations

At 5:39 AM on February 24, 2015, Metrolink Train No. 102 departed the Oxnard Transit Center. Its intended destination was Los Angeles Union Station (LAUS). After negotiating a sweeping arc of track, the train crossed Rose Ave., at Milepost 405 of the Coast Line. Leading the way was Hyundai-Rotem Cabcar No. 645. After negotiating the initial curve, ten miles of straight track lay ahead. Under the control of a student engineer, the diesel pusher train quickly accelerated to seventy miles per hour.

With Metrolink Sr. Engineer Glenn Steele occupying a jump seat behind the student engineer, it would be less than one minute before the cabcar reached Rice Ave. at Milepost 406.23. Unknown to the engineer and his student, an abandoned Ford F-450 work truck lay high-centered on the tracks eighty feet west of Rice Ave. In the early morning darkness, the headlights and emergency flashers of the disabled truck pointed toward the oncoming Metrolink train.

Until it was too late to avoid a collision, neither the student engineer nor Steele determined that the truck’s lights represented a hazard. While traveling at seventy miles per hour, and with less than three tenths of a mile to go, the student engineer saw the headlights looming before the cabcar. Sounding the horn and applying the brakes was insufficient to prevent a collision. On orders from Steele, the student applied emergency braking and both men bailed out, heading toward the rear of the cabcar.

With the brakes engaged, less than 1500 feet separated the cabcar and the work truck. As momentum carried the entire train forward, the impact with the truck was catastrophic. The pilot, a blade intended to clear debris from the tracks, detached from its support structure and disappeared beneath the cabcar. As the wreckage traveled along the tracks, the cabcar and its following coaches derailed and whipped in opposite directions. As the first two cars rotated and toppled on their sides, the whipsaw effect injured dozens of passengers and crew. One week later, Sr. Engineer Glenn Steele succumbed to his injuries.

In early reports, Metrolink touted the crash energy management (CEM) features of the Hyundai-Rotem cabcar. Without its safety features, a spokesperson said, the severity of the incident could have been greater. A preliminary report by the National Transportation Safety Board (NTSB) made such statements seem hasty and ill informed. By September 2015, the NTSB had determined that both the steel within the pilot and welds in its structural supports were deficient. Further, the entire assembly had ripped loose at stress levels below its design criteria.

After receiving an NTSB report regarding failure of the pilot assembly, Metrolink officials skirted discussions regarding any potential design flaw or culpability in the collision. Instead, Metrolink management initiated a conference call with its board members. During that call, the Metrolink Board approved a one-year lease of forty BNSF freight locomotives at a total of $20,000 per day. According to Metrolink Chief Executive Art Leahy, the forty freight locomotives would soon head up all Metrolink trains on their return trips to LAUS. Using the “rule of tonnage”, Metrolink management wanted to rule out the possibility of another deficient pilot or cabcar causing injury in a collision. Lost in the publicity regarding this supposed safety measure was the fact that no regional rail carrier in the nation had ever utilized freight locomotives to head up passenger trains.

Citing the unprecedented, yet unspecified safety issues involved with the Hyundai Rotem cabcars, the Southern California Regional Rail Authority (Metrolink) Board sidestepped the California Open Meeting Law. That ill-conceived and illegal action set Metrolink on a path to its potential demise. It also put the executive management team at Metrolink in a position to either defend their actions or place blame on its own board or others yet unnamed.

On December 5, 2015, I attended the “Steel Wheels Conference”, which is the annual meeting for the rail passenger association known as RailPAC. The meeting convened at the Metro Headquarters Building adjacent to LAUS. While on a lunch break, I discovered a long line of BNSF freight locomotives parked on LAUS Track Number 14. With no room to spare in its maintenance yards, Metrolink had redirected at least sixteen of the leased BNSF locomotives to the depot.

In "The Purloined Letter", a short story by American author Edgar Allan Poe, detectives assumed that a blackmailer would conceal a damning letter in an elaborate hiding place. Thus, he hid it in plain sight. In a flash of chutzpah and hubris, the Metrolink executive team decided to hide almost 7,000,000 lb. of BNSF freight locomotives at LAUS.

Soon after their irrevocable one-year lease at $500 per day each ($7,300,000 total), Metrolink discovered that heavy freight locomotives are more expensive to outfit and operate than they originally thought. Although the BNSF locomotives already featured positive train control (PTC), the software version on the BNSF equipment was two generations beyond what Metrolink was using (version 0 vs. 2.0). A new train management computer (TMC) and retrofitted software were required for each BNSF locomotive placed into service. By late December 2015, BNSF locomotives entered into limited service on Metrolink lines. Almost immediately, problems developed with their operation.

With a gross weight of 420,000 lb., an overall length of seventy-four feet and a wheel diameter of forty-two inches, the huge locomotives had difficulty negotiating ten-degree radius curves such as the one approaching Chatsworth Station. As a result, the wheel-trucks on the BNSF locomotives create premature wear on the inside edge of the outboard rail. In a metallurgical process known as spalling, the BNSF wheels shave steel filings off the rails. The dispersion of filings into nearby electrical shunts often shorts out the signal systems along those tight curves.

Although the horns on the BNSF locomotives fall within legal standards, their blaring pitch can make them sound louder than a regular Metrolink horn. With their twelve drive-wheels and massive sixteen cylinder turbocharged diesel engines, the BNSF freight locomotives are louder and create more vibration than their passenger locomotive counterparts. In addition, regardless of their direction of travel, both the BNSF and the Metrolink locomotives generate power, noise and pollution whenever a Metrolink train moves. Despite Metrolink's claims of environmental sensitivity, a double-ender Metrolink train produces almost twice the engine noise and twice the pollution of a single-engine train.

Because of the unprecedented use of freight locomotives in their train consists, Metrolink obtained only a six-month temporary waiver to utilize the BNSF equipment. A stipulation of the temporary waiver was that Metrolink would maintain compliance with all positive train control (PTC) regulations as specified by the Federal Railroad Administration (FRA). With a few of the BNSF locomotives entering service prior to January 1, 2016, their six-month temporary waiver shall soon expire. When the temporary waiver expires, will the FRA recertify the freight locomotives under rules for passenger use or will it require a full audit of their operations?

One requirement of PTC is that the speedometer on each locomotive shall be accurate at any speed above thirty miles per hour. With a freight locomotive geared for long hauls and a top speed of seventy miles per hour, the stipulated variance of five miles per hour (plus or minus) is difficult to achieve. For example, frequent starts, stops and delays for other rail traffic make the use of freight locomotives on the San Fernando Valley line problematic. Often operating at just above the thirty mile per hour threshold, a wide variety of speed sensors can cause the TMC to place the locomotive into “penalty mode”. Once it enters penalty mode, the TMC automatically applies the brakes and stops the train, no matter where it may be along the tracks.

Before the penalized locomotive can resume service, pumps must refill the air reservoirs that supply breaking power to the train. A locomotive that experiences a penalty can stay in service for the balance of that day. However, a penalized locomotive may not reenter passenger service the following day unless Metrolink corrects the anomaly (inaccurate speedometer) and certifies completion of that work. According to the Los Angeles Times, Metrolink was able to average only twelve BNSF freight locomotives in service per day during April 2016. With so few BNSF locomotives in service, the majority of Metrolink trains returning to LAUS are headed-up by Hyundai-Rotem cabcars. This also begs the question; where are the remaining thirty-eight BNSF locomotives?

After the embarrassment of letting the batteries die on the sixteen BNSF locomotives parked at LAUS in late 2015, Metrolink crews jumpstarted those units and repositioned them to the Metrolink Keller Street Yard. To keep their electrical and motive power units in working condition, the non-operating BNSF locomotives remain in temporary storage at the Keller Street Yard. Placed in “automatic mode”, the engines cycle periodically, bringing them up to operating temperature and charging their batteries. Among other things, this periodic cycling of the engines produces wear on the starter motors, flywheels and the diesel engines themselves.

In 2015, a Los Angeles Times article detailed Metrolink’s plans to purchase twenty-nine so-called Tier-4 locomotives. They were touted as state-of-the-art, low pollution passenger locomotives. According to the article, Metrolink intends to replace up to forty-nine of its aging and ill-maintained passenger locomotives over the next several years. Meanwhile, forty BNSF Tier-1 (high powered, high pollution) freight locomotives sit largely idle in the middle of Downtown Los Angeles. Hidden from public view, cycling their massive engines, these locomotives pump out untold amounts of air pollution into the Los Angeles Basin.

Metrolink’s temporary waiver to operate the BNSF freight locomotives will soon expire. When it does, it will be appropriate for the FRA, the California Public Utilities Commission (CPUC), the South Coast Air Quality Management District (AQMD) and the Southern California Regional Rail Authority (SCRRA) to conduct a complete audit of operations and practices at Metrolink.

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By James McGillis at 01:04 PM | Railroad Safety | Comments (0) | Link

Fifth Street at Las Posas Road Now the Deadliest Rail Crossing in Ventura County - 2016

 

Fifth Street at Las Posas Road Now the Deadliest Rail Crossing in Ventura County

April 21, 2016, the Fifth Street at Las Posas Road grade crossing in Camarillo, California regained the title of “Deadliest Rail Crossing in Ventura County”. Around 6 PM, Garrett Vongunten, 26, piloted his 2015 Harley Davidson motorcycle south on Las Posas Road toward Fifth Street. On the rear seat, Nadya Unger, 23, rode as his passenger. With the late afternoon sun in their eyes, they approached the railroad crossing at an undetermined speed.

At 4:33 p.m. that day, Metrolink Train No. 117 had departed Los Angeles Union Station, heading toward its final destination at the East Ventura Station. Near 6:00 PM, the train approached Las Posas Road from the east at normal speed, which can be as high as seventy miles per hour.

If the traffic control system operated properly at the grade crossing, the approaching train would activate warning bells, flashing lights and crossing gates to warn vehicular traffic of an oncoming train. According to Federal Railroad Administration (FRA) guidelines, the rail crossing gates should be down at least twenty seconds prior to a train crossing Las Posas Road.

For reasons that included impairment from unspecified drugs and possible excessive speed, Vongunten may have seen the warning lights and gates too late to stop safely. As a result, Vongunten’s motorcycle broke through the crossing gate arm and struck the side of the Metrolink train. Passenger Nadya Unger died at the scene and Vongunten sustained critical injuries, including partial loss of one leg. The motorcycle, missing its operator, its passenger and its front wheel, came to rest upright, facing in the opposite direction of original travel. "You could assume that the motorcycle wasn't in the middle of the track per se because of the location that it ended up," California Highway Patrol officer Gregory Bowcock told the Ventura County Star newspaper.

With the collision unseen by the Metrolink engineer, Train No. 117 proceeded to the Oxnard Transit Center, which was its next scheduled stop. Prior to arrival in Oxnard, a passenger who had witnessed the collision notified the train’s conductor of the event. Metrolink held the train in Oxnard until officials could inspect it for signs of damage. A preliminary report indicated that there was evidence of a side impact, including motorcycle parts embedded into a coach and blood on the side of that coach.

In recent years, there have been multiple train collisions on the Oxnard Plain. In February 2015, a train collision at the Fifth St. and Rice Ave. grade crossing in Oxnard took the life of Metrolink Senior Engineer Glenn Steele. By that time, Fifth & Rice had gained notoriety as the “deadliest rail crossing in Ventura County”. In recognition of the many deaths and injuries at Fifth & Rice, Congresswoman Julia Brownley (D-Westlake Village) secured $1.5 million in federal funds for the design of a grade separation at that location.

With the recent death of Nadya Unger, the Las Posas Road and Fifth Street grade crossing now takes the mantel as “deadliest rail crossing in Ventura County”. Here is a chronology of four prior rail collisions at Fifth & Las Posas:

- At 10:49 AM on December 30, 2013, as an Amtrak train passed by, a car entered the grade crossing at Fifth St. and Las Posas Rd. The driver of the vehicle died at the scene and a nearby railroad service worker received injuries resulting from the accident.

- At 10:30 AM on January 24, 2014, crews responded to a train collision at Fifth St. and Las Posas Rd. A seventy-seven year old woman who drove her minivan into the side of a passing Amtrak train succumbed to her injuries at the scene.

- At 8:25 AM on April 23, 2015, a Union Pacific freight train collided with an SUV at the intersection of Fifth St. and Las Posas Rd. The driver, a fifty-seven year old man, drove through the crossing gate arm and into the side of the freight train. The driver succumbed to his injuries at the scene.

- At 10:30 AM on November 21, 2015, a twenty-three year old man drove his car through the crossing gate and into the side of a moving Amtrak train at Fifth St. and Las Posas Rd. At the time of the collision, the crossing gate arm was down and the safety lights were flashing. The driver died days later at a local medical center.

In less than three years, there have been five fatal train collisions at Fifth & Las Posas. The common denominator of all five collisions was that the crossing gates were down, warning lights were flashing and bells were ringing. Even so, each ill-fated vehicle entered the railroad right of way and collided with a moving train. There is no evidence that any one of the five most recent fatal accidents at Fifth & Las Posas was a suicide.

Unlike the Fifth & Rice grade crossing, the Fifth & Las Posas grade crossing has only the minimal safety features mandated by law. At the tracks, Rice Ave. is a divided road, with overhead safety lights, signage, and four crossing gates intended to seal the rail corridor from errant vehicles. At the tracks, Las Posas Rd. is undivided, with no overhead safety signage and only two crossing gates. Even if the gates were down, a driver could cross over the double-yellow lines and drive around the crossing gates. To the unsuspecting driver, the Las Posas Rd. southbound approach to Fifth St. looks like a little-used rural grade crossing.

On Friday April 22, 2016, one day after the death of Nadya Unger and the critical injury to Garrett Vongunten, the Ventura County Transportation Commission (VCTC) voted to support a half-cent transportation sales tax for Ventura County. Nineteen of the fifty-eight counties in California have such a tax, including all the major counties in Southern California. If it makes the November 2016 ballot, the measure will still require approval by a two-thirds majority of county voters. If it passes that hurdle, the new sales tax will provide $70 million annually, earmarked for transportation improvement projects within Ventura County.

Five fatal train collisions at Fifth St. and Las Posas Rd. should be enough to place that grade crossing at the top of Ventura County transportation improvement projects. Suggested improvements include realigning Las Posas Rd. to make it a divided road as it crosses the tracks, installing overhead warning signs and creating a four-gate system of vehicle barriers. Although foot traffic is light at that location, the new safety plan should include sidewalks and pedestrian gates there, as well.

Proposed upgrades to the rail crossing will not stop speeders from trying to beat a train to the crossing nor end inattentive driving, but they will increase the chances that motorists will receive warning in time to stop safely at Fifth & Las Posas for an oncoming train. I hope that public officials throughout Ventura County support a half-cent sales tax dedicated solely to transportation improvement projects.

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By James McGillis at 02:01 PM | Railroad Safety | Comments (1) | Link

Mismatched Braking Systems on Metrolink Trains Presage Disaster - 2016

 

Mismatched Braking Systems on Metrolink Trains Presage Disaster

On October 1, 2015, I wrote about Southern California regional rail passenger carrier Metrolink’s decision to lease forty Burlington Northern Santa Fe (BNSF) freight locomotives. In September 2015, the National Transportation Safety Board (NTSB) had notified Metrolink that serious safety deficiencies existed on their Hyundai-Rotem cabcars. The deficiencies involved the February 24, 2015 Oxnard Metrolink collision that injured scores of passengers and took the life of Metrolink Senior Engineer Glenn Steele.

In Oxnard, the “pilot”, a blade that rides just above track level at the front of each cabcar, had failed in a collision with the work truck. As the Metrolink cabcar swept over the truck, the pilot detached and disappeared into the wreckage. Speculation was strong that the detached pilot had contributed to the derailment of the cabcar and the several coaches riding behind it.

Information from NTSB to Metrolink and then via Dan Weikel of the L.A. Times to the public pointed to structural failure. The steel in both the pilot and its support struts was too porous to withstand the load of the Oxnard collision. In addition, welds between the struts and the pilot showed gaps or porosity that weakened the entire assembly. Confronted with an obvious public safety hazard, Metrolink made a snap decision to place a locomotive at each end of every train set.



On December 31, 2015, I rode on one of the first “double-ender” Metrolink trains traveling from Chatsworth to Los Angeles Union Station (LAUS). It was quite a sight to see a 420,000 lb. BNSF locomotive pulling a five-coach train back toward LAUS. The conductor on the train told me that both the BNSF locomotive and the Metrolink locomotive at the other end provided motive power while operating in either direction.

Citing available statistics for the weight of each locomotive and various Metrolink coaches, I wrote in October 2015, “Riding on four axles, current Metrolink diesel locomotives weigh 280,000 lb. At over 420,000 lb., the six-axle BNSF freight locomotives are fifty percent heavier. A 2015 five-car Metrolink train weighed approximately 460,000 lb. By adding a freight locomotive at one end, each "heavy iron" BNSF train set will weigh 880,000 lb., an increase of ninety-one percent.”

The sole purpose of adding the BNSF locomotives was to assure that any motor vehicle encountered on the tracks would be obliterated. Still unclear was how the braking systems on a double-ender would perform while stopping a 440-ton train. I reflected my concern by titling my October 1, 2015 article, “Metrolink Plans for Live Brake-Tests of BNSF ‘Heavy Iron’ Train-Sets on Commuter Tracks”.

At the Chatsworth Station on March 15, 2016, I discovered the answer to my questions about “heavy iron” and braking safety. The answer is that Metrolink double-ender train sets appear to be unsafe. The newly configured Metrolink train sets are a hodgepodge of engines and coaches. The BNSF freight locomotives are better suited to dynamic (engine) braking, rather than using their pneumatic braking system. Each train set also includes an ill-maintained Metrolink locomotive pushing from the rear. In normal “stop and go” usage between Metrolink stations, both locomotives rely on their pneumatic braking systems.

In between the two locomotives are the heavy, steel-sheathed Hyundai-Rotem coaches and lighter monocoque aluminum Bombardier Bi-level coaches. While both locomotives rely on pneumatic “brake blocks” similar to old-fashioned brake shoes, the Hyundai-Rotem coaches employ outboard disk brakes. Depending on their state of refurbishment, the Bombardier Bi-level coaches appear to utilize various combinations of disk brake and block brake systems.

Each locomotive and coach in any train set connects to its mates with high-pressure air hoses. When the engineer applies the pneumatic brakes, every block or disk in the system activates, creating friction and heat, thus slowing the train. With such diversity in ages and types of braking systems, each wheel-truck may receive a different level of braking power, leading to different stress and patterns of wear.

By Metrolink’s own admission, the agency does not conduct major preventative maintenance or periodic overhauls of its locomotive fleet. The agency prefers, instead, to run its locomotives until breakdown, and then conduct maintenance sufficient only to get a broken locomotive back in service. While allowing its current fleet of locomotives to self-destruct on the tracks, Metrolink is spending $338 Million in taxpayer money on new "Tier-4" locomotives. Metrolink may or may not conduct preventative maintenance on its locomotive braking systems. Since Metrolink does not publish information regarding maintenance of braking systems, no one knows.

In addition to aging and mismatched locomotives, Bombardier Bi-level coaches, are included in virtually every Metrolink train set. With over one million miles of service each, wheels with flat spots are a common problem on the Bombardier Bi-level coaches. On those coaches, some wheel-trucks include retrofits to disk brakes while others appear to utilize the older brake-block systems. With so many mismatches and deficiencies elsewhere, the relatively small disk brakes on the newer Hyundai-Rotem coaches and cabcars absorb much of the total braking load.

With all of the mismatched coaches and locomotives, the easiest way to detect brake wear on a Metrolink train is to inspect the Hyundai-Rotem brake rotors, which ride outboard of the wheels. While conducting a casual inspection of the Hyundai-Rotem brakes, I was shocked to see that every visible brake rotor displayed thermal-fatigue cracks (heat checking) radiating from the hub towards the outside edges of the rotors.

I am not a metallurgical engineer, but I have driven many vehicles that include disk brakes. The Hyundai-Rotem disk brakes are larger and feature pneumatic actuation. Otherwise, automotive disk brakes are quite similar to the Hyundai-Rotem type. After an automotive brake inspection, no competent mechanic would allow me to drive away with extensive thermal damage evident on my rotors. With the heat-induced cracks that I recently discovered on Hyundai-Rotem brake rotors, why are those damaged safety components still rolling on Metrolink coaches today? As Metrolink knows from the deadly Glendale (2005), Chatsworth (2008) and Oxnard (2015) collisions, greater attention to safety might prevent the next Metrolink rail disaster.

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By James McGillis at 11:36 PM | Railroad Safety | Comments (1) | Link

One Year After a Metrolink Engineer's Death, Agencies Largely Ignore Rail Safety at Oxnard Crash Scene - 2016

 

One Year After a Metrolink Engineer's Death, Agencies Largely Ignore Rail Safety at Oxnard Crash Scene

In the predawn hours of February 24, 2015, Metrolink Train No. 102 struck a disabled Ford F-450 work truck and trailer at the Fifth St. and Rice Ave. grade crossing in Oxnard, California. Over thirty passengers were injured and Metrolink Senior Engineer Glenn Steele later died from his injuries. After a twenty-four hour driving odyssey from Tucson, Arizona to Oxnard, Mr. Jose Sanchez-Ramirez had made a wrong turn on to the Union Pacific Coast Line tracks. After high centering his rig eighty feet from the intersection, Sanchez-Ramirez had turned on his emergency flashers and left the scene.

After the resulting fiery crash of the Metrolink train, police found Sanchez-Ramirez half a mile from the crash scene, in obvious distress. On February 22, 2016, The Ventura County District Attorney filed a misdemeanor charge of vehicular manslaughter against Jose Sanchez-Ramirez. Immediately, the Union Pacific Railroad, the California Public Utilities Commission (CPUC), Metrolink, the LOSSAN Rail Corridor Agency, Ventura County and the City of Oxnard all breathed a collective sigh of relief. With charges now filed against the truck driver, they were all “off the legal hook” for their collective negligence.

Union Pacific Railroad owns the Coast Line tracks and is responsible for safety of its railroad infrastructure. The CPUC, in conjunction with Caltrans is responsible for rail safety at grade crossings such as Fifth Street, which is also State Highway 34. Metrolink, which operated Train No. 102, is responsible for maintaining its equipment in safe condition. LOSSAN is a joint powers agency responsible for the overall safety of the second busiest rail passenger corridor in the nation. Ventura County and Oxnard are jointly responsible for maintenance of roadways that intersect with the rail corridor.

For each of the above-mentioned public entities to have remained silent and immobile for the past year is unconscionable. Yet, they all have a perfect excuse. In the case of injury accidents on the nation’s rail lines, the National Transportation Safety Board (NTSB) becomes the lead investigative agency. On March 19, 2015, the NTSB issued a preliminary accident report regarding the Oxnard Metrolink collision. Since then, it has published no further findings.

Until the NTSB issues its final report, the responsible companies, agencies and local governments continue to eschew responsibility for the accident. In fact, each of those entities shares part of the blame for the unsafe conditions or for the faulty equipment involved. Let us look at each entity and its involvement in the collision.

Union Pacific Railroad – For an undetermined time prior to the collision, the Union Pacific Railroad had ignored a damaged steel pylon base that supported the Rice Ave. crossbuck. The crossbuck consists of overhead warning signs and flashing lights that activate when a train approaches. Loose wiring on the vehicle warning gates was visible after the crash. At the time, there were no reflective plastic safety pylons installed to warn motorists from turning on to the railroad tracks.

The California Public Utilities Commission (CPUC) – Various CPUC accounts hold over $42 million in federal funding intended for rail crossing upgrades in California. As of March 2015, the CPUC had allocated none of that money for repair of dangerous crossings such as Fifth & Rice. At the behest of Congresswoman Julia Brownley (D-26th District), the CPUC promised to investigate conditions at the Oxnard crash scene. If the CPUC has indeed studied the issue, it has published no findings on the internet.

Metrolink – The Southern California passenger rail agency has denied responsibility for the Oxnard collision. Instead, they have deflected legal responsibility while pointing to Jose Sanchez-Ramirez and his employer as the responsible parties. For their injuries on Train No. 102, Metrolink has offered passengers no compensation at all. Instead, they offered a one-month free pass for travel on the Metrolink system. If any injured passenger had accepted such a "payment in kind", would Metrolink have later used that fact to absolve itself of contingent liability? I hate to say so, but I believe that they would.

Late in 2015, the NTSB contacted Metrolink with urgent safety information. The NTSB had discovered an equipment failure on Metrolink’s Hyundai-Rotem Cabcar No. 645, which was involved in the Oxnard collision. From the sketchy reports that came from Metrolink headquarters, we can deduce that the “pilot” on Cabcar No. 645 was deficient. The pilot is a blade-like device designed to clear debris from the tracks, thus preventing derailment. Also called an “anti-climbing device”, the pilot on Cabcar No. 645 had detached during the collision with the F-450 work truck. As it disappeared under the cabcar, the detached pilot may have contributed to the catastrophic derailment and decoupling of the cabcar and the second coach in Train No. 102.

In response to the identified safety threat, Metrolink leased forty freight locomotives from Burlington Northern Santa Fe Railroad (BNSF). Starting in late 2015, Metrolink began phasing in the use of BNSF locomotives on all of its routes. On outbound trips, a BNSF locomotive trails each train like a caboose. After reaching the end of the line, the BNSF locomotive then heads-up each Metrolink train on its return trip to Los Angeles Union Station. Using this “heavy iron” approach, a BNSF freight locomotive should be able to lift any stalled vehicle or debris off the tracks, thus preventing future derailments.

By its own admission, Metrolink no longer maintains its aging fleet of diesel locomotives. On March 11, 2016, a twenty-four year old Metrolink locomotive caught fire in Pomona, California. With the severity of the damage, it is likely that Metrolink locomotive No. 865 will never go back into service. In an ill-conceived and unsafe plan to save money, Metrolink runs its locomotives until they fail and then repairs them only as necessary to put them back into service.

The recent fire in Pomona calls into question the safety and reliability of the entire Metrolink fleet. If Metrolink no longer performs routine maintenance on its locomotives, do they still test, maintain and repair defective braking systems? Even after the derailment and decoupling of the cabcar and the second coach in Oxnard, inadequate breaking systems allowed Locomotive No. 870 to push the entirety of Train No. 102 well past the Rice Ave. grade crossing.

Finally, there is a question regarding the second coach in Train No. 102. It was a Bombardier Bi-level Coach with one million miles of service. In its final report regarding the 2005 Glendale Metrolink collision, the NTSB formally warned Metrolink. It said that the “fixed worktables” in Metrolink Bombardier Bi-level Coaches had contributed to injuries and possible deaths in that incident. After the 2008 Chatsworth Metrolink collision, the final NTSB accident report described death and near dismemberment when passenger torsos impinged upon similar fixed worktables.

Metrolink has since refurbished most of the aging Bombardier coaches in its fleet. Part of that process involves the installation of new fixed worktables, which have a thicker cross-section. Still, passenger at least maintains that derailed Coach No. 206, in which he was injured, had not been upgraded before the February 24, 2015 Oxnard Metrolink collision. That coach, along with the rest of Train No. 102 sits rusting in a Metrolink yard at Moorpark, California. Was the passenger injured by an unsafe, “killer worktable” of the type identified to Metrolink ten years prior? With a quick inspection, the passenger's assertion should be easy to prove or disprove.

By deploying BNSF freight locomotives weighing 460,000 lb., a Metrolink five-car train set now weighs approximately 880,000 lb. As an unintended consequence of this added weight, the obsolete and ill-maintained Metrolink diesel locomotives are now breaking down at an ever-increasing rate. Recently, at the Chatsworth Station, I discovered that Metrolink has secretly replaced some of its own F59PH locomotives with similar equipment provided by R&B Leasing, Inc. As my photos from that station show, Metrolink now has a BNSF locomotive at one end and an R&B locomotive at the other end of some trains. Sadly, Metrolink is becoming an outsourced passenger carrier that can no longer run trains with its own locomotives.

LOSSAN Rail Corridor Agency – Managing all passenger train activity on the Coast Line, from San Diego to San Luis Obispo, LOSSAN is a de facto arm of the Orange County Transportation Authority (OCTA). With collocation and co-management at its headquarters in Orange, California, the agency pays little attention to Ventura County and beyond. How often does any LOSSAN agency staffer travel on its rail network to visit Fifth & Rice in Oxnard?

LOSSAN staff should make the arduous, time-consuming and oft delayed rail trip from Orange County to Ventura County. There, at the Fifth St. and Rice Ave. grade crossing they would discover gross deficiencies in safety management. Remember, it was there that Metrolink Senior Engineer Glenn Steele lost his life in February 2015. For LOSSAN staff, it is time to leave its headquarters and visit the “scene of the crime”. After the site visit, I suggest that LOSSAN make a public report about its findings.

Ventura County and City of Oxnard – The saddest agency on the Southern California transportation map is the Ventura County Transportation Commission (VCTC). With no half-cent sales tax for transportation projects, the commission can do little more than wave its hands and hope for the best. Before and after the 2015 Oxnard Metrolink collision, the agency called for action regarding safety improvements at the Fifth St. and Rice Ave. grade crossing. They informed us that it was a serial disaster, with death and dismemberment possible at any moment. What did the City of Oxnard and the County of San Buena Ventura do to mitigate safety issues at that grade crossing during the past year? You guessed it… nothing but verbiage.

The tracks in question are in Oxnard, which is in Ventura County. They are part of the Union Pacific Railroad Coast Line. The LOSSAN Rail Corridor Agency manages passenger trains upon those tracks. On those same tracks, Metrolink Train No. 102 collided with Mr. Sanchez-Ramirez’s abandoned work truck. With the overlapping responsibilities of the companies and agencies listed above, it is impossible to know which entity did what and when. Among them all, here is what has happened in the past year to fix the problems existing at Fifth & Rice.

Unknown parties have replaced a concrete and wrought iron safety wall, previously destroyed by Metrolink Cabcar No. 645. The loose and ragged wiring on the grade crossing gates is no longer visible to the casual observer. Union Pacific, we assume, replaced the southbound Rice Ave. crossbuck with all new equipment, including LED warning lights and gate-arm flashers. Unknown parties have affixed two (count them, two) plastic safety pylons at the scene. Like two small candles in the night they stand, one on either side of the railroad tracks where Jose Sanchez-Ramirez made his erroneous and deadly turn. To her credit, Congresswoman Julia Brownley (D-Westlake Village) recently announced that $1.5 million in federal funds has been secured to create a preliminary design for the proposed Rice Avenue railway-highway grade crossing improvement project.

Occasionally, I visit the makeshift memorials for those who have lost their lives at Fifth & Rice in Oxnard, California. It is a place of personal disaster for many people over many years. Sometimes I feel that I am the only interested person who goes there to observe. If the staff of the legal entities responsible for the problem would jointly visit the site, what might happen? If they did, I know that they and their employers would be shamed into action.

Southern California is famous for its disastrous floods, wildfires and earthquakes. In the past fifteen years, all of those natural disasters combined have taken fewer lives than the grade crossing at Fifth St. and Rice Ave. in Oxnard. Union Pacific Railroad, California PUC, Caltrans, LOSSAN, Metrolink, City of Oxnard and Ventura County, it is well past time to act.

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By James McGillis at 12:28 PM | Railroad Safety | Comments (0) | Link