Washington state’s lightweight Talgo trains that carried 800,000 Amtrak Cascades passengers last year should be replaced “as soon as possible” with railcars that can provide better protection in a crash, the National Transportation Safety Board (NTSB) proposed Tuesday, in its final hearing about the fatal high-speed derailment in December 2017 on a curve near DuPont.

But the safety board placed primary blame for the crash on Sound Transit, which owns the $181 million corridor, for failing to require safety improvements near the curve, where the 80 mph speed limit dropped to 30 mph.

All three passengers who died would likely have survived in a stronger railcar, said NTSB investigator Michael Hiller. The aluminum, Spanish-designed cars uncoupled and the wheels broke loose. Like missiles, he said, the parts hit vehicles and other railcars that plunged onto Interstate 5.

Talgo replied that the forces from the crash far exceeded what any passenger railcars are designed to withstand.

“Unfortunate accidents under extreme conditions happen, that are not attributable to the equipment, as in this case. Talgo’s expert analysis differs from the speculation of the NTSB staff and we stand behind Talgo’s crashworthiness and safety record worldwide,” said an e-mail message from Nora Friend, a company vice president.

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At the hearing in Washington, D.C., the NTSB discussed in length what led up to the accident.

“The probable cause of the Amtrak 501 derailment was the Central Puget Sound Regional Transit Authority’s [Sound Transit] failure to provide an effective mitigation for the hazardous curve without Positive Train Control in place, which allowed the Amtrak engineer to enter the 30-mile-per-hour curve at too high of a speed, due to his inadequate training on the territory and inadequate training on the newer equipment,” said a statement read by Chairman Robert Sumwalt.

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The Washington State Department of Transportation (WSDOT) chose to start passenger rail service without demanding solutions for known hazards, the statement added. And the Federal Railroad Administration allowed railcars that weren’t strong and well-secured, “causing damage to railcar body structures which then failed to provide occupant protection, resulting in passenger ejections, injuries and fatalities,” the NTSB found.

“I’m just amazed at the amount of failure that goes along here,” said board vice president Bruce Landsberg.

“We have five or six or seven different organizations that all say safety is their primary responsibility, and yet nobody seems to be responsible,” he said. “And it just flows all the way throughout the entire operation here, from the very top management down to the lower levels.”

The crash occurred on the inaugural southbound Cascades trip on a rebuilt track corridor from Tacoma to Lakewood and DuPont on Dec. 18, 2017. Engineer Steven Brown had completed only one training trip at the controls on a southbound trip and two northbound.

Seattle-Portland trips have since reverted to slower tracks through the Tacoma Narrows, winding along Puget Sound. The safety board said Washington state is procuring new railcars. WSDOT aims to restart the Lakewood route, which is 10 minutes faster and avoids interference by freight trains, sometime this year.

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Asked if WSDOT will abandon its lightweight Talgos in response to NTSB findings, state rail spokeswoman Janet Matkin replied by email: “We need time to review them and work with other agencies to determine the next steps for Amtrak Cascades service. We’ll share those decisions once they are made.”

The Talgos have been popular in Washington state, because their suspension system lets trains manage curves comfortably at higher speed than conventional trains.

Talgo has been serving the Cascades corridor more than 20 years “with an impeccable safety record,” said Friend. She characterized the cause of the accident as “human error by running at 82 mph on a curve limited to 30 mph.”

Tuesday’s hearing revealed that a speed alarm beeped as the doomed locomotive surpassed 80 mph north of the curve. In-cab video showed the engineer seemed confused, and checked the dashboard for 20 crucial seconds rather than looking out window as the train closed in on the curve, Hiller said. This was a general speed alarm, to get down to the standard 79 mph, and not prompted by the upcoming 30 mph curve.

Brown had little experience in the Siemens Charger locomotive, whose speed alarm differed from other types.

The sign warning of the 30 mph zone was a full two miles before the curve, a stopping distance used by heavier freight trains. No warning sign appeared at the one-mile point where Amtrak engineers should slow. The NTSB suggested supplemental signs in the area.

As they have since 1967, board members also called for nationwide positive train control (PTC), a satellite-based network that automatically halts a speeding or wayward train before it can derail or collide with something.

Sounder commuter trains owned by Sound Transit now operate under PTC, and the agency built equipment that Amtrak can also use on the Lakewood line. Congress mandated these systems after a 2008 head-on crash in Southern California, but at railroad companies’ behest stretched the Dec. 31, 2015, deadline to 2018, and in some cases 2020.

Board member Jennifer Homendy said she has read 150 NTSB investigative reports that found PTC would have averted a crash.

Homendy took particular aim at the Talgo Series VI railcars, about 21 years old, that were grandfathered — in her words, given an exemption — into the Cascades line in 1999. She pointed out the Federal Railroad Administration approved those while Amtrak ran on the slower Narrows route, and not for the faster Lakewood section.

Safety-board members dwelled on a blue child seat that flew from a railcar, landing in the wreckage. Just one minute before the crash, the father took the child to the lavatory. They both survived.

“Think about that next time you have to change a diaper, that it may not be the worst thing in the world,” Sumwalt said. NTSB requests Amtrak install anchors to secure child seats.

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Board members did applaud Amtrak reforms made since the wreck, such as hiring new CEO Richard Anderson and a new safety officer.

“They are probably a different railroad than they were at the time of this — of this tragedy. And I think we need to acknowledge that, and show appreciation for the work that they are doing,” Sumwalt said.

Sound Transit, in a statement Tuesday, said that since the crash it has imposed a gradual reduction in speed, from 79 mph to 50 mph to 30 mph, heading south toward DuPont. The area will also be a “crew focus zone” where engineers and conductors must say aloud the speed restrictions as they arrive. Both changes are also called for in the NTSB findings.

No Sound Transit employees have been disciplined or reassigned because of the derailment, and the agency has yet to review the final NTSB report, said Sound Transit spokesman Scott Thompson.

Rail enthusiasts Jim Hamre, Zack Willhoite and Benjamin Gran, all in the breakaway eighth passenger car, were killed in the crash.

“Could this accident have been prevented? The answer is a resounding yes,” Sumwalt said in opening remarks that emphasized the engineer was set up to fail. “Three people didn’t have to die. Fifty-seven people on the train and eight people on the ground didn’t have to be injured.”