2015 Philadelphia train derailment NTSB report
Adopted May 17 2016
Railroad Accident Report
Derailment of Amtrak Passenger Train 188
May 12, 2015
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.
- Figures and Tables
- Abbreviations and Acronyms
- Executive Summary
vi 1.Investigation and Analysis 1 1.1Synopsis 1 1.2Accident Scenario 2 1.3Amtrak 5 1.4Analysis of the Engineer’s Actions 6 1.4.1Loss of Situational Awareness 9 1.4.2Need for Improved Crew Training and Advanced Technologies 11 1.5Signal and Train Control Information 13 1.5.1Positive Train Control 14 1.5.2Two-Person Crews 17 1.6Train Information 20 1.6.1Postaccident Testing 21 1.7Personnel Information 21 1.8Survival Factors 22 1.8.1The Derailment Sequence 22 1.8.2Damage to Passenger Car Windows and Injuries 23 1.8.3Occupant Protection in Derailment Scenarios 26 1.9Emergency Medical Response 28 1.9.1Incident Management 28 1.9.2Transportation of the Injured 29 1.9.3Amtrak’s Passenger Accountability System 36 1.10Factors Not Contributing to This Accident 37 2Postaccident Actions 38 2.1NTSB Recommendations 38 2.2FRA Emergency Order 40 2.3Amtrak 41 3Conclusions 42 3.1Findings 42 3.2Probable Cause 44 4Recommendations 45 4.1New Recommendations 45 4.2Previously Issued Recommendations Arising from this Accident 46 4.3Previously Issued Recommendation Reiterated in this Report 47 4.4Previously-Issued Recommendations Classified in this Report 48
- Board Member Statements
- Appendix A: Investigation
- Appendix B: Transcript of Radio Transmissions
- Appendix C: Sample of Recent NTSB Accident Investigations with Two-Person Crews Involving Noncompliance with Signals or Instructions
Figures and TablesEdit
- Figure 1. Accident scene.
- Figure 2. Train 188 intended route
- Figure 3. Train 188's route through Philadelphia.
- Figure 4. Amtrak routes throughout the United States.
- Figure 5. PTC (ACSES) was installed on the Northeast Corridor in 2000.
- Figure 6. Accident site showing derailed cars, catenary structures locations.
- Figure 7. Damaged catenary supports (left); example of undamaged catenary supports (right).
- Figure 8. Photograph showing damaged right side of car 3.
- Figure 9. Close-up of damaged windows on right side of car 4.
- Figure 10. Map of hospitals near derailment and accident patients treated as of 1:30 a.m. the night of the accident.
- Figure 11. Map of hospitals near derailment and more even distribution of accident patients.
- Table 1. Injuries.
- Table 2. Cab Signal Indications
- Table 3. Amtrak Train 188.
Abbreviations and AcronymsEdit
|AAR||Association of American Railroads|
|ACSES||Advanced Civil Speed Enforcement System|
|AIS||Abbreviated Injury Scale|
|Amtrak||National Railroad Passenger Corporation|
|ATC||automatic train control|
|BLET||Brotherhood of Locomotive Engineers and Trainmen|
|CFR||Code of Federal Regulations|
|Conrail||Consolidated Rail Corporation|
|CRM||crew resource management|
|DOT||US Department of Transportation|
|EMS||Emergency Medical Services|
|FAST||Fixing America’s Surface Transportation|
|FRA||Federal Railroad Administration|
|GAO||Government Accountability Office|
|MARC||Maryland Area Regional Commuter|
|MCI||mass casualty incident|
|Metra||Northeast Illinois Regional Commuter Railroad|
|NORAC||Northeast Operating Rules Advisory Committee (Operating Rulebook)|
|NPRM||notice of proposed rulemaking|
|NTSB||National Transportation Safety Board |
|OEM||Office of Emergency Management (Philadelphia)|
|PFD||Philadelphia Fire Department|
|PPD||Philadelphia Police Department|
|PTC||positive train control|
|SEPTA||Southeastern Pennsylvania Transportation Authority|
|USC||United States Code|