SOUND TRANSIT POINT DEFIANCE BYPASS PROJECT INCIDENT REVIEW NOVEMBER 11, 2019 Final Report PREPARED BY L & H CONSULTING GROUP, LLC P.O. NUMBER 176601 OP PAGE INTENTIONALLY LEFT BLANK L & H Consulting Group, LLC INTRODUCTION ........................................................................ 1 1 BACKGROUND .............................................................. 2 TABLE OF 2 APPROACH TO THE INCIDENT REVIEW ...................... 4 CONTENTS 3 FEDERAL & STATE REGULATIONS & INDUSTRY PRACTICE IN SAFETY CERTIFICATION ........................ 6 Federal Railroad Administration (FRA) ......................................... 6 Federal Transit Administration (FTA) ............................................ 9 Washington State Regulations .................................................... 13 Industry Practice in Safety Certification ..................................... 14 4 SOUND TRANSIT SAFETY & SECURITY CERTIFICATION PROGRAM ........................................ 15 5 GAP ANALYSIS & FINDINGS ....................................... 17 PDBP Contractual Relationships & Agreements .........................17 Sound Transit’s Safety Management Plans ................................. 21 Sound transit’s Hazard Management Process & Procedures .... 26 Sound Transit’s Safety Certification Process & Procedures ...... 29 Sound Transit’s Internal Departmental Coordination for the PDBP ............................................................................................. 33 Summary of All Gap Analysis Findings ........................................ 36 6 SUMMARY & RECOMMENDATIONS ......................... 39 Summary....................................................................................... 39 Recommendations ....................................................................... 39 ACRONYMS & DEFINITIONS ...................................................42 FIGURES Figure 1. Point Defiance Bypass Project (2017) ................................ 2 Figure 2. Safety Risk Management Process ................................... 27 Figure 3. Industry Probability Definitions ...................................... 27 Figure 4. Probability Definitions (2015 Sound Transit Agency SSMP) 28 Figure 5. Sound Transit Safety and Security Management Committees ...................................................................... 33 Figure 6. Sound Transit Safety and Security Risk Approval Structure .......................................................................... 34 TABLES Table 1. PDBP Milestones ................................................................. 15 Table 2. Gap Analysis Findings ........................................................ 36 Table 3. Acronyms ........................................................................... 42 Table 4. Definitions.......................................................................... 43 APPENDICES A KICKOFF MEETING MINUTES B DOCUMENTS REVIEWED C INTERVIEW QUESTIONS D SOUND TRANSIT INTERVIEWEES L & H Consulting Group, LLC INTRODUCTION Following its investigation of the December 18, 2017 Amtrak derailment from a bridge near DuPont, WA (“Amtrak derailment”), the National Transportation Safety Board Throughout this report, (NTSB) made recommendations to the Central Puget Sound terms included in the Regional Transit Authority (Sound Transit). Sound Transit is Acronyms & Definitions addressing these NTSB recommendations in part by section are bolded upon contracting with an independent third-party to conduct an first use. incident review of the Amtrak derailment. The review emphasizes the Sound Transit safety and security certification process utilized for the Point Defiance Bypass Project (PDBP). This Incident Review Report is organized into the following sections: Section 1: Background of the Accident and NTSB Investigation Section 2: Approach to the Incident Review Describes the step-by-step approach utilized to identify any deficiencies in Sound Transit’s PDBP’s safety risk management and safety certification processes, and to develop recommendations to address identified deficiencies. Section 3: Federal and State Regulations and Industry Practice in Safety Certification Reviews applicable Federal and State regulations, rules and industry practices, and an inventory of commuter rail systems’ safety certification programs. Section 4: Sound Transit Safety and Security Certification Program Reviews Sound Transit’s safety certification program, including the agency’s safety-related plans and PDBP documents, and the interviews conducted with Sound Transit staff involved in the PDBP and its safety certification program. Section 5: Gap Analysis and Findings Provides a gap analysis and associated set of findings based on Sections 1 through 4 that identify strengths and deficiencies associated with Sound Transit’s safety certification program. Section 6: Summary and Recommendations Provides a summary of this incident report and recommendations to address gaps and deficiencies identified in the Section 5 gap analysis and findings. Point Defiance Bypass Project L & H Consulting Group, LLC Incident Review Final Report Page 1 1 BACKGROUND In 2006, the Washington State Department of Transportation (WSDOT) developed its long-range plan for improving Amtrak Cascades service between Vancouver, British Columbia, and Portland, Oregon. WSDOT applied for and received federal American Recovery and Reinvestment Act (ARRA) intercity high-speed rail grants in 2009 and 2010 to undertake the first set of improvements included in their long-range plan. After being awarded approximately $751.5 million in funding, WSDOT began 20 rail infrastructure projects, including the PDBP. The $181 million PDBP was WSDOT’s final project under the ARRA grant funding package. Initiated in late 2014 and completed by the 2017 grant funding deadline, the purpose of the PDBP was to improve passenger train reliability by reducing congestion with freight trains and travel times, by means of re-routing existing service to an inland route, as shown in Figure 1 below. Figure 1. Point Defiance Bypass Project (2017) Point Defiance Bypass Project L & H Consulting Group, LLC Incident Review Final Report Page 2 Sound Transit was the contractor for WSDOT on the construction of the PDBP. Sound Transit in turn hired contractors to undertake the construction work while performing the safety certification in-house. Sound Transit completed safety certification of the PDBP in accordance with the agency’s 2015 Safety and Security Management Plan (SSMP). The Sound Transit Safety and Quality Assurance (SQA)1 Department provided the PDBP Safety Certification Verification Report in October 2017, which included the signed Certificates of Conformance. This report was accepted by the Rail Activation Committee (RAC). By accepting the PDBP Safety Certification Verification Report, Sound Transit only certified that the PDBP was ready for WSDOT and Amtrak to initiate pre-revenue testing, not that the pre-revenue testing was completed. After pre-revenue testing was completed, Sound Transit did not receive any reports from Amtrak or WSDOT of issues with the operating system. The PDBP Safety Certification Verification Report was not updated to reflect completion of the pre-revenue testing or of operational readiness. On December 18, 2017, Amtrak began its inaugural operation of the PDBP revenue service. At approximately 7:33 am Pacific Standard Time that morning, westbound Amtrak Train #501 was on single main track from Tacoma when it approached a 30-mph curve at too high of a speed and derailed at milepost 19.8 on the Lakewood sub-division near DuPont, Washington. Several passenger cars fell from a bridge at the curve onto Interstate 5 and hit highway vehicles. The train consisted of two locomotives and twelve passenger cars. Three Amtrak passengers died in the accident and multiple people were injured. The NTSB conducted an investigation of the Amtrak Train #501 derailment and issued its Accident Report on May 21, 20192. The NTSB’s determination of the probable cause of the derailment was Sound Transit’s “failure to provide an effective mitigation for the hazardous curve without positive train control in place, which allowed the Amtrak engineer to enter the 30-mph curve at too high of a speed due to his inadequate training on the territory and inadequate training on the newest equipment. Contributing to the accident was the Washington State Department of Transportation’s decision to start revenue service without being assured that safety certification and verification had been completed to the level determined in the preliminary hazard assessment.” Based on its investigation, the NTSB Accident Report includes both new and reiterated recommendations to the Federal Railroad Administration (FRA), and new recommendations to Amtrak, WSDOT and Sound Transit. The three recommendations specific to Sound Transit are: Immediately conduct a review of all operating documents and ensure that safety mitigations are applied with uniformity throughout the entirety of your territory. (R-19-030) In areas of your territory where you are a host of a tenant railroad, coordinate with all current and any prospective tenants on the development of operating documents including timetables, general orders, and special instructions. (R-19-031) Review your internal process for safety certification and verification, perform a gap analysis, and develop an action plan to address the deficiencies identified in the gap analysis and detailed in this report to enhance