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.
During the recent presidential inauguration, I planned to get as far away as possible from all broadcast and online media sources. After reviewing my old blog articles, I decided that the Hole in Wall Campground in the Mojave National Preserve was the place to go. In the lower elevations of the campground, my mobile telephone might access a cell tower somewhere near Needles, California. At the upper reaches, terrestrial signals are weak, with only AM radio and an occasional text message transiting through the ether.
As it happened, my winter camping trip to the desert was epic. In my coach, I had vintage wines, great food and forced-air, propane heating at my fingertips. My electrical power emanated from two 6-volt “golf cart batteries”. Combined, they offered 12-volts of power to my lights and appliances. The system allowed for “deep cycle” usage and quick recovery during recharge. In the campground, as the temperature dipped below 40-degrees, I set the thermostat as high as 71-degrees. As it converts from a liquid to a gaseous state, propane expands by a factor of 270. Even with extensive burning, my ten gallons of propane would suffice for several nights of warmth. As the night progressed, I could have worn shorts and t-shirt inside.
Overnight, I set the temperature at a comfortable 60-degrees. As I slept in luxury, the furnace cycled five or six more times. When I awoke the next morning, it was raining. I pushed a button on the control panel and the electric-powered awning extended fully over the outside door of my coach. After sprinting through a light shower, I retrieved my old Honda EX1000 generator from the bed of my pickup truck. After pouring what we euphemistically call “gasoline” into its integral tank, I prepared to pull the recoil starter.
Over the past decade, the ethanol, or corn alcohol in our domestic fuel supply had twice clogged up the carburetor. Contemporary generators and automobiles have a pressurized fuel system that seals itself from leaks when not in use. My old Honda generator relied on gravity to feed the carburetor, thus there was no automatic shutoff of the fuel supply. As long as there was fuel in the tank, any change in barometric pressure would expand or contract the air in the fuel tank, thus sending a few drops of fuel into the carburetor.
The medical community entreats us not to eat or drink foods that contain corn syrup. Science proved long ago that corn syrup would clog our arteries and lead to diabetes and incipient heart failure. As with corn syrup in the human body, so it is with “corn fuel” in an engine designed for real gasoline. By leaving a small amount of gas in the tank during storage, I had twice gummed-up the carburetor. Each time, the engine failed to start, requiring a costly rebuild. In my case, it took two such episodes to determine that the gas tank on my EX1000 must be empty when placed into storage. By now, it had been more than two years since I had run the generator.
Since my EX1000 uses a conventional carburetor, it needs to be “choked” in order to fire-up and start running. For those who have lived only in the “fuel injection era”, choking means physically limiting the air supply to the engine in order to increase the fuel-to-air ratio. Upon startup, it gives you more “bang for the buck”, as they used to say. After achieving “lift off”, so to speak, one can open the choke incrementally. Once the oil in the crankcase warms up, fully opening the choke allows the engine to run efficiently.
I looked down at the choke-slider from above and behind the unit. From that odd angle, the hieroglyphics indicating that the choke was “open” or “closed” made no sense. After erroneously sliding it to the full-open position, I proceeded to pull on the recoil starter twenty or thirty times, with no success. By then, water was puddling four-inches deep beneath the aft-end of the coach and rain was whipping in my face. Enough was enough. I shoved the EX1000 under the coach and went inside to dry off.
The LED indicators in my coach showed that my “house batteries” were down to one-third of their normal power. Despite having to brave intermittent rain showers, I would dash out every couple of hours and run the engine on my Titan truck. Through an attached cable, the alternator on the Titan’s V-8 engine recharged my coach batteries. By nightfall, it was pouring rain, but the batteries recovered to two-thirds power. Feeling better about my power supply, I went inside, planning to stay there until sunup.
When I sat down at the dinette, the seat of my pants felt wet and cold. In my haste to run the truck engine, I had left my shirttail hanging out of my two-piece rain suit. The shirttail was soaked and so was I. In order to warm up, I had to remove all of my wet clothes and replace them with dry apparel. In the desert cold, one can rapidly succumb to hypothermia. Since I was still on limited battery power, I did not raise the thermostat for warmth. Instead, I relied on my own metabolism to warm my clothes and me. When I sat back down, even the cushions of the dinette were damp. Would my bouts with the cold and the wet ever end?
After dark, it became colder still, so I wore three layers on my torso and pajamas beneath my jeans. On my feet were two pairs of socks and warm slippers. In order to save battery power, I used portable lights and even kept the radio off. Television was not an option. Normally I stay up until at least midnight, but it was so cold and dismal that I went to bed around 10 PM. Soon after getting in bed, I spilled a small portion of white wine on the bed sheets. In order to stay dry, I had to leave my previously warm spot and resettle on the opposite side of the bed.
As I lay listening to the rain and wind, the only other sound was the blower on the furnace, which was cycling on and off. Each time the furnace relighted, I would turn it down a degree or two, hoping to conserve battery power. By midnight, I had turned it down to about 52-degrees. Two days later, I discovered an air-gap where the slide-out meets the chassis of the coach. That small air gap had the same effect as leaving a door ajar. With the high winds that night, it felt like a fan was blowing cold air into the coach.
As I slept fitfully, the wind and the rain battered the outside of my coach. After the weather front passed through at 1 AM, the wind began gusting to over forty miles per hour. During previous camping trips, I had always put a “four-by-four” piece of wood under each of the leveling glides on the coach. Since the motorized leveling system on my current coach is so easy to use, I had become complacent. Instead of placing a solid piece of wood beneath each glide, I had lowered them directly on to the wet desert sand.
The “full-room slide out” was fully extended, thus cantilevering a lot of weight over the open desert. As the winds picked up, the coach would heal like a sailboat under sail. In reality, the coach did not move much, but it felt unstable and ready to blow over. My lucky stroke was that the pickup truck was upwind, helping break some of the wind forces. Also, the aerodynamic front end of the coach faced into the wind.
Whether it is our voting choices or our camping practices, sometimes we humans act against our self-interest. If I had not been obsessed with saving battery power, I would have used the motorized system to retract the slide-out into the coach. Rocking in my unstable cradle that night, I recalled that if the house batteries dipped below 11.5-volts, the hardwired carbon monoxide alarm would start wailing. Worse yet, the alarm would not stop until the batteries were sufficiently recharged. By the time I remembered that, it was freezing outside, so I did not venture out and run the truck engine.
The potential for a wailing alarm was more powerful than my fear that the coach would overturn, so I left the slide-out extended. With four-inches of water pooled beneath the rear leveling glides, that was not a wise idea. In the end, everything stayed upright. Still, for the better part of three hours, it felt like I was inside the tornado from The Wizard of Oz. After 3 AM, the furnace stopped cycling and the wind gusts seemed to abate, or maybe I passed out, with a pillow over my head.
When I awoke, the sun shown above the low horizon to the east. As its rays struck the back window of the coach, the air inside slowly rose toward 55-degrees. Although the warming trend was encouraging, in order to feel comfortable, I needed more heat. Then, I remembered that a group of campers had spent the night in tents, down at the windiest, coldest part of the campground. How were they feeling that frigid morning, I wondered? After dressing as warmly as I could, I stepped out and walked toward my truck.
On a whim, I dragged the old Honda EX1000 generator out from beneath the coach, “choked it” and then pulled the rope. It fired-up on the first pull. The EX1000 employs some old technology, including what amounts to a small motorcycle engine mated to a 1000-watt generator. Even when warm, it emits pollutants far above a current-generation “CARB Compliant” generator. With gloved hands, I plugged the power cord from the coach into the 120-volt electrical receptacle on the generator. Within 40-minutes, the coach was warm and toasty and the batteries registered two-thirds full. The price I paid for old technology that morning was to inhale exhaust gasses at my otherwise pristine desert campsite.
In order to avoid the exhaust, I explored the bounds of my rustic campsite, including the bed of my pickup truck. There, in a crate that carried my unused four-by-fours was half an inch of solid ice. Since my indoor/outdoor thermometer went missing, I can only assume that it got down to about 25-degrees overnight. Still, as the sun rose and the wind abated, the air warmed to about 45-degrees. Upon further inspection, my trailer tires were showing unusual wear, so I needed to buy new ones before returning home.
After two eventful nights at my desert camp, I headed for Needles, about fifty miles away. On my first trip to the Hole in the Wall Campground, eleven years ago, I had experienced a slow leak in one of my tires. After pumping it up above normal pressure, I hoped to get fifty-miles of travel before it deflated. Then, I had the choice of traveling cross-country on dirt roads to the town of Baker or heading to Needles and purchase new tires there. Good sense prevailed, so I had navigated paved roads and Interstate I-40 to Desert View Mobil, located on the old Needles Highway. Back then, I assumed that buying trailer tires in the desert would be akin to throwing money down a rat hole. Were they not just waiting for a desperate soul like me to fall into their money trap?
As it occurred, that first visit and twice since, the people at Desert View Mobil have treated me to free refreshments while I waited for a refit with new tires on each successive rig. Having bought three sets of tires at Desert View Mobil, I knew they could do the job. As I rolled to a halt, the manager approached me saying, "You know your tires are shredding?" I said, "That's why I'm here". Before he mounted the new tires, I asked him to check my suspension links, which felt loose and wobbly on the road. No, the tires and suspension components I purchased that day were not free, but my new tires were higher quality than I could buy at any local tire store.
Soon, I had all new bolts, links and bushings on the suspension, plus four new eight-ply tires. Each new “wet-bolt” features a grease fitting and unlike the original nylon bushings, the new ones were solid bronze. In the future, I can lubricate the whole suspension system, mitigating excess tire wear and the loose handling I had previously experienced. Longtime Desert View Mobil mechanic, Ricky Wallace and his compatriot had me back on the road in less than three hours. Before I departed, they provided a free grease-job on my wheel bearings. As I headed for I-40, it felt like I was driving a brand new rig.
While writing this article, I researched “Desert View Mobil” on the internet. One image led me to Yelp, which features mostly negative reviews of millions of businesses. The reviews for Desert View Mobil were true to form. Most Yelp reviewers seem to hate all small businesses. Eighty-percent of the Yelp reviews I read were extremely negative. How could my experience with this particular business be so good while many customers felt swindled, overcharged or defrauded?
As I said, Yelp is a “complainer’s paradise”, so do not expect to see any good news there. Also, remember that you are in the town of Needles, in the middle of the Mojave Desert. Nothing is cheaper in the desert. Next door, at the Dairy Queen, I bought the most expensive milkshake of my life. Desert travel is hard on vehicles, whether they are trailers, motor homes or automobiles. Why else would Desert View Mobil stock tires of almost every size? If you limp in on three wheels, as one vintage Savoy trailer did, do not expect a bargain, but do expect to be back safely on the road in short order. As they say, time is money.
Interstate I-40 has more elevation changes than a roller-coaster. If a tire is going to fail, you can expect it to break apart somewhere near Needles. If you travel at high speed and have neglected routine maintenance, you will require help somewhere near High Desert Mobil. When the staff there points out that your tires are bare and your suspension is shot, do not blame them. Blame yourself for not fixing the problem before leaving home. Besides, they offer a two-year written warranty on parts and labor. Just keep the receipt in your glove box and stop in for a safety check each time you pass by.
When I was rolling again, it was too late to drive the 300-miles home. Instead, I headed down the long grade to Park Moabi, along the Colorado River. Although the County of San Bernardino owns Moabi Regional Park, its concessionaire has renamed it “Pirate’s Cove”. Adjacent to old Route-66 and the Colorado River, the park began life in the 1930s as an itinerant travel camp for Dust Bowl escapees. In prime season, the restaurant now serves around 3000 meals each day. Boats from up and down the river flock to its lagoon. After anchoring, boaters can take a water taxi to the restaurant. If you have the time and money, you can take a float-plane ride, a speedboat ride or connect your RV to a full hookup next to the river.
Not wanting to spend the extra ten dollars for a full hookup, I elected to go with “water and power only”. That meant I would have to access the RV dump in the morning. Still, with the outrageous price of $55 for a full hookup near the Colorado River, saving money seemed appropriate. My decision turned out to be a mistake. Instead of spending the night in quiet seclusion by the river, I ended up camping amidst the biggest, loudest party ever. I camped in an area occupied by hard-drinking party-people, all of whom drove high-powered “quad” off-road vehicles. Once I hooked up the water and power, I retreated to my coach. The “Quiet Hour” of 10 PM came and went. Without fail, every ten minutes, someone would fire up his ORV, just to hear the engine rev.
Are you a hard-drinking, “hoot & holler” pirate-type, enamored of high-powered off-road vehicles? If so, Pirate's Cove is the place for you. They tout 3200-miles of off-road trails to drive. With high-revving engines all around and a complete lack of respect for "quiet hours", you will experience a freewheeling atmosphere of loud music, engine fumes and smoky campfires. If you enjoy peace, quiet and have respect for your neighbors, stay as far away from Pirate’s Cove as you can. When you check in, they copy your driver’s license, your vehicle insurance certificate and take your credit card for payment. I do not know who can access all that information, but the potential for identity theft is ever-present. For the reasons stated above, I give Pirate’s Cove management a "no stars" review.
Overnight, some prankster opened both the black-water and gray-water valves on my coach. Only the outside cap retained the effluent. The next morning, when I opened the cap at the RV dump, one-hundred gallons of effluent poured out on the desert soil and on me. Someone had already dumped a bucket-load of horse droppings by the Pirate's Cove RV dump, so I did not feel bad about leaving the area as soon as possible. By the time I cleaned up and departed the scene, it was raining.
For the next 300-miles, the rain did not let up. Near sundown, I caught a glimpse of Simi Valley from the pass at Rocky Peak. Upon arrival at my destination, the rain had stopped and my winter camping experience in the desert was complete.
That was how I spent Inauguration Weekend 2017. Do we have a new president? Was there a protest march the next day? Is there an unconstitutional immigrant ban in effect? Is my Medicare heading for a voucher system? Will Congress slash my Social Security benefits? Apparently, a lot can change when one spends a few nights at a "Hole In The Wall" in the Mojave National Preserve.
"Home Tweet Home", the City of Burbank Tournament of Roses Float
For the past several years, I have attended the unveiling and judging of the City of Burbank Tournament of Roses parade float. Traditionally, the official judging is on New Year’s Eve, just one day before the Rose Parade, in Pasadena, California. Since the Burbank float is one of only a handful of all volunteer efforts, the rollout from the Float Barn is a community event.
Surprisingly, many elements of the 2017 entry; both physical and spiritual, came together this year on January 1 – New Year’s Day. Since New Year’s Day 2017 fell on a Sunday, the parade date shifted to Monday, January 2, 2017. For a moment on New Year’s Day, all activity at the float barn seemed to stop. After a great rush of love and appreciation swept through the open barn door, activities resumed.
It was time to attach the animatronic birds to the frame of the float. With a forklift working as a crane, each large wire-mesh bird received a hydraulic hookup, and then descended toward its slots. With some jiggling and joggling, each bird slid into place. Seemingly out of nowhere, Maria Cady, a florist from nearby Simi Valley and her crew rushed in with half a dozen huge floral displays. Now, the float was complete.
All spectators and nonessential crew cleared the scene, regrouping in the viewing area, at the nearby Burbank - Downtown Station. Like a child who wanted to see his Christmas presents the night before, I hung back and hid in a big blue porta-potty. As I opened the door and started taking pictures, Burbank’s “Home, Tweet Home” float was already on the move.
After following the float out to the street, I ran ahead, rejoining the parade as it entered the viewing area. As soon as it stopped, a jaunty jingle of a tune emanated from four large speakers, hidden in the structure of the float. Various animatronic birds started tilting, swiveling, hammering or riding in and out on a giant tape measure.
Then, without warning, the large birdhouse near the back of the float started to rise. At full extension of its hydraulic tower, the float looked unimaginably tall. As it was when I was a child, the float looked like something out of the Jack and the Beanstalk story to me.
The official judging did not result in a trophy for the Burbank 2017 float. Now it is time to look to the future. Soon, the Burbank Tournament of Roses Association will announce the winner of its 2018 public design contest. As of this writing, the smaller birdhouse still stands on the float chassis, but most other components have disappeared.
As much as possible, salvaged materials from the 2017 float will reappear in the 2018 float. Reuse and recycling are hallmarks of all Burbank Rose Parade floats. For instance, in 2017, recycled bed sheets helped stabilize the rigid foam shell of the float. That recycled bedding helped to make the entire float “walkable”, without fear of falling through. After a full tune-up, the custom designed chassis will return to the Float Barn, ready to support next year’s entry.
Many contemporary Rose Parade floats employ hydraulic motors and cylinders to lift or repetitively move various components. Hidden hydraulics provide the motive power to animate the big floats, yet until the 2017 Burbank entry, no medium-sized float had previously employed a “tower lift”. Unseen and unknown to most parade viewers, “Home, Tweet Home” represented a technological breakthrough for a float of its size. For 2018, the Pasadena Tournament of Roses Association has initiated a "Crown City Innovator" award. The new trophy will be awarded to the float that features the "Most outstanding use of imagination, innovation and technology". With this new category in mind, the 2018 Burbank Rose Parade Float will surely be in the running.
In February 2016, I installed a live webcam at the City of Burbank Float Barn. Seven days each week, you may view live images of the Float Barn. To access the live webcam, go to the homepage of the Burbank Tournament of Roses official website. You may also view the live webcam on my own BurbankFloat.com tribute website. Early in 2017, most of the work parties are on Wednesday’s and Saturdays, so be sure to tune in and watch the action.
Sarah Thomas - New Swim Record of Eighty-two Miles on Lake Powell
In early October 2016, Spokesmodel Carrie McCoy and I traveled to Page, Arizona. From there, we embarked on a four-day, three-night houseboat excursion on Lake Powell. Although Antelope Marina is in Arizona, the upper reaches of the lake are in Utah. When congress created what would become the Western States, no one thought to use watercourses as more natural boundaries. Hence, we now have the “Four Corner” states.
Our first day on the water consisted of navigating our seventy-foot houseboat “up lake” (or up river, as it had once been). Trailing behind us on a line was a twenty-six foot powerboat. After traveling almost twenty-five miles upstream, we beached the large craft. With the churning motors keeping us against the shore, we set out lines, and anchored into the sandy beach. Then we relaxed and enjoyed nightfall aboard our luxury houseboat.
The next morning, we boarded our powerboat and proceeded upstream to explore Lake Powell and its side canyons. Our initial destination was Rainbow Bridge National Monument, which is one of the “Seven Wonders of the Natural World”. The stone arch of Rainbow Bridge itself is enough to strike wonder into the heart of any sighted visitor.
Even with a 250-hp. Evinrude outboard motor to propel us across the water, time and wave action made the trip seem interminable. As we sped along the middle reaches of the lake, it was a harsh ride. While navigating the red and green channel markers, we spotted a small houseboat with flags and banners flying in the wind. As we approached, we saw two small boats and a kayak circling around something in the water.
As we sped past, our hull pushed a bow wave toward the flotilla. Looking over, I spotted someone within that circle of boats, swimming downstream. I was too dumbfounded to take a picture, so there is no evidence of that sighting. After spending a couple of hours at Rainbow Bridge, we returned to our houseboat, perhaps twenty miles downstream. As we progressed, we came upon the same flotilla of boats and again could see someone in the water, swimming downstream.
Before a filet mignon barbeque dinner on our houseboat, the three of the couples who were aboard with us enjoyed our top-deck spa. Then, we repaired to our four separate cabins for a restful night floating on the lake water.
The next day, we again took our powerboat upriver to see Reflection Canyon and Cathedral Canyon, which are two of the most scenic side canyons in the vicinity. As we blasted up river in our powerboat, we came across the little flotilla of boats we had seen the previous day. Nothing had changed except their location. With a swimmer still in the water, the whole group was now farther downstream. During our return to the houseboat on that second day, we again (you guessed it) overtook and passed the flotilla of small boats and its encircled swimmer.
Upon return to our floating condominium, we enjoyed a third evening of festivities, including Carrie and me having the top deck spa to ourselves. Despite a wind change, we again had a restful night aboard. After a hearty brunch on our final morning, we shoved off and piloted the big houseboat down river and back toward Antelope Marina.
As we entered the final few miles of our journey, we came across a group of small boats. Although the houseboat had departed, there were still several small boats surrounding a swimmer or two in the water. Although there was now a second swimmer pacing the first, I recognized the same black swimsuit we had seen for the past several days. At that moment, I realized what was happening. Someone was swimming the length of Lake Powell, without a stop.
From where I stood on the upper deck, I shot one still photo and twenty-six seconds of video. After three days of disbelief, those two shots were all the documentation that I acquired of an epic swim. As it turned out, we had witnessed Sarah Thomas breaking the world record for an unassisted marathon swim. Later, national news reported that Sarah had swum eighty-two miles in fifty-six hours… without stopping or getting out of the water.
As spectators, we watch Olympic swimmers compete in contests up to 1500 meters. To put Sarah Thomas’s accomplishment into perspective, her eighty-two mile swim equals 131,966 meters, or eighty-eight times the length of the longest Olympic swim race. During her quest, Sarah Tomas survived on twice-hourly liquid carbohydrate drinks. For almost two and one half days, Sarah swam, never touching a boat, a rope or a human hand. Congratulations to Sarah Thomas for accomplishing her amazing “new energy” swim.