MEMO: Board members: In May the National Transportation Safety Board (NTSB) issued its report on the tragic Amtrak derailment that occurred almost two years ago after an operator took an Amtrak Cascades train through a 30 mph curve at 79 mph. While Amtrak acknowledged and accepted liability for the accident, four of the 53 findings in the NTSB report were pertinent to Sound Transit. There were also 26 recommendations, three of which were directed to Sound Transit. These findings and recommendations all relate to the fact that while Sound Transit does not operate any of our own rail service in the area of the derailment, as the owner of the track, we carry important safety certification and oversight responsibilities. Sound Transit purchased this segment of track back in 2005 so that we could extend Sounder commuter rail from Tacoma to Lakewood. However, in order to buy it, we were required to purchase the entire segment from Tacoma to the Thurston County line. You will recall that immediately following the release of the NTSB report, I launched an independent, third-party review to evaluate the incident from top to bottom. That review is now complete, and the findings are sobering. I write to you today to share the details of the report and inform you of the immediate actions I am taking in response. Effectively immediately, our Chief Executive Safety & Quality Officer has been removed from his position. In addition, I am initiating the process to reorganize and separate the safety and quality management functions so that a separate and distinct office will be laser-focused solely on our safety responsibilities. Quality assurance functions will be separately managed. .The new safety division will be led on an interim basis by Moises Gutierrez, a knowledgeable and skilled leader from a wholly different department until a national recruitment brings us a new Chief Safety Officer. Both Moises and the new Chief Safety Officer will report directly to me. The independent review was undertaken by the Oregon-based L & H Consulting Group. The consultant's report is attached for your review. The report identifies a number of preventable errors, including failing to properly adhere to safety plan procedures. Specifically: • • A project-specific Safety and Security Management Plan was not prepared for the Point Defiance Bypass. Pre-revenue simulated service was not fully performed as required by Sound Transit policy. • • • Proposed hazard mitigations were not appropriately briefed and the safety certification package was not submitted to the responsible Executive Activation Group for final certification approval and ultimate sign-off by the CEO. Responsibilities as the host railroad were not sufficiently understood. Sound Transit staff wrongly believed that WSDOT, not Sound Transit, was responsible for overseeing all activities related to Amtrak training and qualifications. The consultant’s report includes 22 distinct recommendations, including some focused on improving our hazard analysis program more broadly. Many have already been implemented, while the others are in various stages of development. We intend to implement all 22 recommendations fully and promptly. Before Sound Transit allows Amtrak to resume Cascades service on the Point Defiance Bypass, we will verify that all necessary changes have been made to correct identified deficiencies. We will not assume, but rather rigorously verify, that Amtrak’s personnel training and testing programs for operation are more than sufficient, and that their general orders to their crew have been appropriately amended to reflect operations on Sound Transit track. Measures that we have already implemented include the following: • • • Positive Train Control is now up and operating on the corridor. Sound Transit's timetable now includes a crew focus zone for Amtrak train crews as well as Sound Transit’s crews. Graduated speed restrictions have been implemented approaching the curve, going from 79 mph to 50 mph to 30 mph, with more signage. The consultant shared the NTSB's recognition that deficiencies contributing to this tragedy arose in part because of the extraordinarily unique arrangement where one agency (WSDOT) funds capital improvements and contracts for the service provided by another agency (AMTRAK), which operates the service over territory owned by a third agency (Sound Transit), which runs no service over that territory but is responsible for ensuring the safety of the other operators that do. Indeed, the consultant could find no similar situation elsewhere in the United States. Despite this extremely unique framework, it was Sound Transit's responsibility as the host railroad to identify, execute, and enforce certain discrete safety-related functions. I continue to have confidence in Sound Transit’s practices in certifying the safety of services we operate. But our reforms will not only remedy deficiencies in our safety certification of Amtrak’s Cascades service. They will further strengthen our already successful track record in certifying and commissioning Link light rail expansions. There can be no compromises when it comes to safety. We are grateful for the thoroughness of our consultant's independent review as well as the NTSB investigation. You have my personal commitment that we will execute appropriate responses to every pertinent finding and recommendation to ensure that safety is priority #1 at Sound Transit. The complete report of our consultant with findings and recommendations is attached. Please do not hesitate to contact me on this or any other matter. -P