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NTSB finds 'weak safety culture' at Amtrak after fatal Pennsylvania crash

iStock/Thinkstock(NEW YORK) -- Following a 19-month investigation, the National Transportation Safety Board identified 20 different factors that contributed to the April 2016 crash that killed two veteran Amtrak employees and injured 39 passengers when the company's train struck a backhoe and derailed in Chester, Pennsylvania.

Investigators said Amtrak had a "weak safety culture" where employees frequently took short cuts and put on-time performance over safety.

The NTSB previously disclosed toxicology reports indicating marijuana in the system of the train's engineer and cocaine or opioids in the systems of the killed maintenance workers, but they did not conclude that drugs impaired the employees at the time of the crash.

While drug use did not have a "direct causal link to this accident," according to investigators, it is a reflection of a lax safety culture at Amtrak, they said.

The Federal Railroad Administration revised its federal drug testing rules to include Maintenance of Way workers. This rule went into effect on June 12, 2017. Previously DOT regulations only required drug testing for locomotive engineers, trainmen, conductors, switchmen, locomotive helpers, utility employees, signalmen, operators and train dispatchers.

These rules establish minimum requirements for drug testing. Rail companies are free to expand them.

On Monday the FRA said it was adding certain semi-synthetic opioids such as hydrocodone, hydromorphone, oxymorphone and oxycodone to its testing.

“The opioid crisis is a threat to public safety when it involves safety-sensitive employees involved in the operation of any kind of vehicle or transport,” said Transportation Secretary Elaine Chao. “The ability to test for a broader range of opioids will advance transportation safety significantly and provide another deterrence to opioid abuse, which will better protect the public and ultimately save lives.”

Railroad repairs were ongoing in the days leading up to the fatal accident. A night foreman was found to have lifted a track closure while a backhoe remained on the track. The day foreman did not restore the closure, according to investigators, leading to a train striking the backhoe at nearly 100 mph.

NTSB chairman Robert Sumwalt described the mistake by the foremen as "the fundamental error of the night."

“Under no circumstances should you clear foul times with men and equipment fouling the track,” said Joe Gordon, who investigated track and engineering issues for the board.

Among the contributing factors to the crash were lack of communication between employees, improper establishment of work zones, lack of shunts and pressure from managers to keep trains on time.

Positive Train Control had been installed in the Northeast Corridor where the crash occurred, but investigators said a series of human errors, such as not properly establishing the work zone, circumvented PTC technology.

Despite Amtrak requiring the use of shunts at the time, investigators said the maintenance workers did not have them at the accident site. The NTSB said the shunts could have signaled that the track was occupied and prevented the crash.

Amtrak has since purchased thousands of the devices.

Amtrak spokeswoman Kimberly Woods told ABC News that Amtrak has "taken a series of actions to improve workplace safety at Amtrak," but did not respond when asked what exactly those actions are.

The engineer of the involved train was fired following the accident, according to Amtrak.

An NTSB spokesperson said the list of board recommendations would be posted later Tuesday.

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