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. 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.
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 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.
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.
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?
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?
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.
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 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 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.