NTSB/RAR-16/02
PB2016-103218
Notation 8714B
Adopted May 17 2016
Railroad Accident Report
Derailment of Amtrak Passenger Train 188
Philadelphia, Pennsylvania
May 12, 2015
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National
Transportation
Safety Board
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490 L‘Enfant Plaza, SW.
Washington. DC. 20594
National Transportation Safety Board. 2016. Derailment of Amtrak Passenger Train 188 Philadelphia, Pennsylvania, May 12, 2015. Railroad Accident Report NTSB/RAR-16/02. Washington, DC.
Abstract: At 9:21 p.m. eastern daylight time on May 12, 2015, eastbound Amtrak passenger train 188 derailed in Philadelphia, Pennsylvania, with 245 passengers and 8 Amtrak employees on board. The train had just entered the Frankford Junction curve—where the speed is restricted to 50 mph—at 106 mph. As the train entered the curve, the locomotive engineer applied the emergency brakes. Seconds later, the train derailed. Eight passengers died, and 185 others were transported to area hospitals.
This report addresses the following safety issues: crewmember situational awareness and management of multiple tasks; positive train control; passenger railcar window systems and occupant protection; and transportation of the injured after mass casualty incidents.
As a result of the investigation of this accident, the National Transportation Safety Board makes recommendations to Amtrak, the Federal Railroad Administration, the American Public Transportation Association, the Association of American Railroads, the Philadelphia Police Department, the Philadelphia Fire Department, the Philadelphia Office of Emergency Management, the mayor of the city of Philadelphia, the National Association of State EMS (Emergency Medical Services) Officials, the National Volunteer Fire Council, the National Emergency Management Association, the National Association of EMS Physicians, the International Association of Chiefs of Police, and the International Association of Fire Chiefs.
The National Transportation Safety Board (NTSB) is an independent federal agency dedicated to promoting aviation, railroad, highway, marine, and pipeline safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The NTSB makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews.
The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation, "accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties. .. and are not conducted for the purpose of determining the rights or liabilities of any person." 49 CFR § 831.4. Assignment of fault or legal liability is not relevant to the NTSB's statutory mission to improve transportation safety by investigating accidents and incidents and issuing safety recommendations. In addition, statutory language prohibits the admission into evidence or use of any part of an NTSB report related to an accident in a civil action for damages resulting from a matter mentioned in the report. 49 USC § 1154(b).
For more detailed background information on this report, visit http://www.ntsb.gov/investigations/dms.html and search for NTSB accident ID DCA15MR010. Recent publications are available in their entirety on the Internet at http://www.ntsb.gov. Other information about available publications also may be obtained from the website or by contacting: National Transportation Safety Board, Records Management Division, CIO-40, 490 L'Enfant Plaza, SW, Washington, DC 20594, (800) 877-6799 or (202) 314-6551
NTSB publications may be purchased from the National Technical Information Service. To purchase this publication, order product number PB2016-103218 from: National Technical Information Service, 5301 Shawnee Rd., Alexandria, VA 22312, (800) 553-6847 or (703) 605-6000, http://www.ntis.gov/
Contents
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Figures and Tables ................................................................................................................................................................................................................................................................................................................................................................................................ | iii
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Abbreviations and Acronyms ................................................................................................................................................................................................................................................................................................................................................................................................ | iv
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Executive Summary ................................................................................................................................................................................................................................................................................................................................................................................................ | vi
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| 1. | Investigation and Analysis ................................................................................................................................................................................................................................................................................................................................................................................................ | 1
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| 1.1 | Synopsis ................................................................................................................................................................................................................................................................................................................................................................................................ | 1
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| 1.2 | Accident Scenario ................................................................................................................................................................................................................................................................................................................................................................................................ | 2
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| 1.3 | Amtrak ................................................................................................................................................................................................................................................................................................................................................................................................ | 5
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| 1.4 | Analysis of the Engineer’s Actions ................................................................................................................................................................................................................................................................................................................................................................................................ | 6
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| 1.4.1 | Loss of Situational Awareness ................................................................................................................................................................................................................................................................................................................................................................................................ | 9
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| 1.4.2 | Need for Improved Crew Training and Advanced Technologies ................................................................................................................................................................................................................................................................................................................................................................................................ | 11
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| 1.5 | Signal and Train Control Information ................................................................................................................................................................................................................................................................................................................................................................................................ | 13
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| 1.5.1 | Positive Train Control ................................................................................................................................................................................................................................................................................................................................................................................................ | 14
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| 1.5.2 | Two-Person Crews ................................................................................................................................................................................................................................................................................................................................................................................................ | 17
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| 1.6 | Train Information ................................................................................................................................................................................................................................................................................................................................................................................................ | 20
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| 1.6.1 | Postaccident Testing ................................................................................................................................................................................................................................................................................................................................................................................................ | 21
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| 1.7 | Personnel Information ................................................................................................................................................................................................................................................................................................................................................................................................ | 21
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| 1.8 | Survival Factors ................................................................................................................................................................................................................................................................................................................................................................................................ | 22
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| 1.8.1 | The Derailment Sequence ................................................................................................................................................................................................................................................................................................................................................................................................ | 22
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| 1.8.2 | Damage to Passenger Car Windows and Injuries ................................................................................................................................................................................................................................................................................................................................................................................................ | 23
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| 1.8.3 | Occupant Protection in Derailment Scenarios ................................................................................................................................................................................................................................................................................................................................................................................................ | 26
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| 1.9 | Emergency Medical Response ................................................................................................................................................................................................................................................................................................................................................................................................ | 28
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| 1.9.1 | Incident Management ................................................................................................................................................................................................................................................................................................................................................................................................ | 28
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| 1.9.2 | Transportation of the Injured ................................................................................................................................................................................................................................................................................................................................................................................................ | 29
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| 1.9.3 | Amtrak’s Passenger Accountability System ................................................................................................................................................................................................................................................................................................................................................................................................ | 36
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| 1.10 | Factors Not Contributing to This Accident ................................................................................................................................................................................................................................................................................................................................................................................................ | 37
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| 2 | Postaccident Actions ................................................................................................................................................................................................................................................................................................................................................................................................ | 38
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| 2.1 | NTSB Recommendations ................................................................................................................................................................................................................................................................................................................................................................................................ | 38
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| 2.2 | FRA Emergency Order ................................................................................................................................................................................................................................................................................................................................................................................................ | 40
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| 2.3 | Amtrak ................................................................................................................................................................................................................................................................................................................................................................................................ | 41
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| 3 | Conclusions ................................................................................................................................................................................................................................................................................................................................................................................................ | 42
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| 3.1 | Findings ................................................................................................................................................................................................................................................................................................................................................................................................ | 42
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| 3.2 | Probable Cause ................................................................................................................................................................................................................................................................................................................................................................................................ | 44
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| 4 | Recommendations ................................................................................................................................................................................................................................................................................................................................................................................................ | 45
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| 4.1 | New Recommendations ................................................................................................................................................................................................................................................................................................................................................................................................ | 45
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| 4.2 | Previously Issued Recommendations Arising from this Accident ................................................................................................................................................................................................................................................................................................................................................................................................ | 46
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| 4.3 | Previously Issued Recommendation Reiterated in this Report ................................................................................................................................................................................................................................................................................................................................................................................................ | 47
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| 4.4 | Previously-Issued Recommendations Classified in this Report ................................................................................................................................................................................................................................................................................................................................................................................................ | 48 |
Board Member Statements ................................................................................................................................................................................................................................................................................................................................................................................................ | 49
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Appendix A: Investigation ................................................................................................................................................................................................................................................................................................................................................................................................ | 57
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Appendix B: Transcript of Radio Transmissions ................................................................................................................................................................................................................................................................................................................................................................................................ | 58
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Appendix C: Sample of Recent NTSB Accident Investigations with Two-Person Crews Involving Noncompliance with Signals or Instructions ................................................................................................................................................................................................................................................................................................................................................................................................ | 60 |
Figures and Tables
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Figure 1. Accident scene. ................................................................................................................................................................................................................................................................................................................................................................................................ | 1
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Figure 2. Train 188 intended route ................................................................................................................................................................................................................................................................................................................................................................................................ | 3
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Figure 3. Train 188's route through Philadelphia. ................................................................................................................................................................................................................................................................................................................................................................................................ | 4
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Figure 4. Amtrak routes throughout the United States. ................................................................................................................................................................................................................................................................................................................................................................................................ | 5
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Figure 5. PTC (ACSES) was installed on the Northeast Corridor in 2000. ................................................................................................................................................................................................................................................................................................................................................................................................ | 15
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Figure 6. Accident site showing derailed cars, catenary structures locations. ................................................................................................................................................................................................................................................................................................................................................................................................ | 23
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Figure 7. Damaged catenary supports (left); example of undamaged catenary supports (right). ................................................................................................................................................................................................................................................................................................................................................................................................ | 23
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Figure 8. Photograph showing damaged right side of car 3. ................................................................................................................................................................................................................................................................................................................................................................................................ | 24
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Figure 9. Close-up of damaged windows on right side of car 4. ................................................................................................................................................................................................................................................................................................................................................................................................ | 24
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Figure 10. Map of hospitals near derailment and accident patients treated as of 1:30 a.m. the night of the accident. ................................................................................................................................................................................................................................................................................................................................................................................................ | 30
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Figure 11. Map of hospitals near derailment and more even distribution of accident patients. ................................................................................................................................................................................................................................................................................................................................................................................................ | 30
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Table 1. Injuries. ................................................................................................................................................................................................................................................................................................................................................................................................ | 2
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Table 2. Cab Signal Indications ................................................................................................................................................................................................................................................................................................................................................................................................ | 13
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Table 3. Amtrak Train 188. ................................................................................................................................................................................................................................................................................................................................................................................................ | 20 |
Abbreviations and Acronyms
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| AAR |
Association of American Railroads
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| ACSES |
Advanced Civil Speed Enforcement System
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| AIS |
Abbreviated Injury Scale
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| Amtrak |
National Railroad Passenger Corporation
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| ATC |
automatic train control
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| BLET |
Brotherhood of Locomotive Engineers and Trainmen
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| CFR |
Code of Federal Regulations
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| Conrail |
Consolidated Rail Corporation
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| CT |
computed tomography
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| CRM |
crew resource management
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| DOT |
US Department of Transportation
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| EMS |
Emergency Medical Services
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| eTicketing |
electronic ticketing
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| FAST |
Fixing America’s Surface Transportation
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| FRA |
Federal Railroad Administration
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| GAO |
Government Accountability Office
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| MARC |
Maryland Area Regional Commuter
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| MCI |
mass casualty incident
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| Metra |
Northeast Illinois Regional Commuter Railroad
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| MP |
milepost
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| NORAC |
Northeast Operating Rules Advisory Committee (Operating Rulebook)
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| NPRM |
notice of proposed rulemaking
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| NTSB |
National Transportation Safety Board
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| OEM |
Office of Emergency Management (Philadelphia)
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| PFD |
Philadelphia Fire Department
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| PPD |
Philadelphia Police Department
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| PTC |
positive train control
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| SEPTA |
Southeastern Pennsylvania Transportation Authority
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| USC |
United States Code
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