DUPONT, Wash. -- The deadly DuPont train derailment was a multi-agency failure, the National Transportation Safety Board (NTSB) said Tuesday after concluding its investigation into the 2017 crash.
"Could this accident have been prevented? The answer is a resounding 'Yes,'" NTSB chairman Robert Sumwalt said.
Read Sumwalt's entire opening statement from Tuesday's hearing
The NTSB report said multiple agencies are at fault for the Dec. 18, 2017 crash that killed three people and injured 65 others.
The train cars derailed over I-5 on the first-ever passenger trip on the route, going more than twice the speed limit around a dangerous curve.
The engineer didn't slow down in time before reaching the curve at the Point Defiance Bypass. He came in going 78 miles per hour; the speed limit was 30.
However, the NTSB isn't blaming him. It's blaming all of the agencies that put him on that track and in an unfamiliar locomotive on that day.
"It set up the engineer to fail," Sumwalt said.
The investigation found failures in training, signage and track and rail car safety.
First and foremost, positive train control (PTC) was not operating on the Point Defiance Bypass. That system would have automatically slowed down the train and, investigators say, prevented the deaths and injuries.
Agencies like Sound Transit and Amtrak could have decided against starting service on the new route before installing PTC. That didn't happen.
"We figured out and we know how did this all occur, but why did it occur?" said David Beninger, an attorney at Luvera Law Firm representing dozens of the victims. "Why are the federal agencies not doing proper oversight? Why are there so many players that are delegating their duties for safety to other people? Why didn't Amtrak pick up the ball and ensure the loop was closed and this was safe to operate under?"
These are all questions the NTSB is recommending the agencies at fault take into consideration.
Many of the injuries were found to come from unsafe rail cars that were essentially expired. The Talgo series six-rail-car did not meet U.S. safety standards and was grandfathered in under an agreement with the Federal Railroad Administration. The panel said using the cars "poses unnecessary risk to railroad passenger safety when involved in a derailment or collision."
And then, there was training and signage. The engineer had only executed one southbound trip on this route before taking it on the maiden passenger voyage that ended in death and disaster. He also missed the one speed-limit sign two miles ahead of the turn, telling him to go from nearly 80 miles per hour down to 30.
"It's all too easy to blame it on individuals but this was an institutional problem, and it involved a number of institutions Amtrak first and foremost," Beninger said.
Since the crash and the start of this investigation, several changes have been made. PTC is installed on the tracks and the training programs are much more thorough.
WSDOT has said they would wait until after this investigation to start using the Point Defiance Bypass again. On Tuesday, they said they will review the board's recommendations before deciding the next steps for the Amtrak Cascades service.
As for the victims, Beninger said they're still fighting to get medical bills covered by the companies found to be at fault.