The September 12, 2008 head-on collision resulted in 25 fatalities and more than 100 injuries. As a result of its findings, the NTSB recommended that the Federal government require audio and image recorders in the cabs of all locomotives and in cab car operating compartments.
According to records from the wireless provider, on the day of the accident, while on duty, both the Metrolink engineer and the Union Pacific conductor used wireless devices to send and receive text messages. The engineer also made non- business related voice calls while on duty. "For the transportation industry, this accident demonstrates that we must find a way to wrap our arms around the pervasive problem of transportation operators using wireless devices while on the job, whether that job is driving a bus, flying an airplane, or operating a train," NTSB Chairman Deborah A. P. Hersman said.
Although Metrolink prohibits its engineers from using wireless devices while operating a train, the privacy afforded by the locomotive cab, once the train leaves a station, makes it difficult for violations of operating rules to be discovered through ordinary management supervision or efficiency testing, the NTSB noted. On previous occasions, the Metrolink engineer also had allowed unauthorized persons to join him in the locomotive cab and even operate the train.
The NTSB also cited the lack of a positive train control system (PTC) as a contributing factor in the accident. A positive train control system would have stopped the Metrolink train short of the red signal, thus preventing the accident. "This accident shows us once again that the safety redundancy of PTC is needed now," Hersman said. "It can and will save lives even when operators ignore safety rules or simply make mistakes."
With the completion of this accident investigation, the NTSB made two recommendations to the Federal Railroad Administration:
- Require the installation, in all controlling locomotive cabs and cab car operating compartments, of crash- and fire-protected inward- and outward-facing audio and image recorders capable of providing recordings to verify that train crew actions are in accordance with rules and procedures that are essential to safety as well as train operating conditions. The devices should have a minimum 12-hour continuous recording capability with recordings that are easily accessible for review, with appropriate limitations on public release, for the investigation of accidents or for use by management in carrying out efficiency testing and system-wide performance monitoring programs.
- Require that railroads regularly review and use in-cab audio and image recordings (with appropriate limitations on public release), in conjunction with other performance data, to verify that train crew actions are in accordance with rules and procedures that are essential to safety.
