Index:Derailment of Amtrak Passenger Train 188 Philadelphia, Pennsylvania May 12, 2015.dvju.djvu

Title	Derailment of Amtrak Passenger Train 188 Philadelphia, Pennsylvania May 12, 2015-Accident Report
Author	National Transportation Safety Board
Source	djvu
Progress	Proofread—All pages of the work proper are proofread, but not all are validated
Transclusion	Transclusion check required

Pages (key to Page Status)

Cover — i ii iii iv v vi vii viii 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Contents

1. Figures and Tables ................................................................................................................................................................................................................................................................................................................................................................................................

   iii

2. Abbreviations and Acronyms ................................................................................................................................................................................................................................................................................................................................................................................................

   iv

3. Executive Summary ................................................................................................................................................................................................................................................................................................................................................................................................

   vi

4. 1.

   Investigation and Analysis ................................................................................................................................................................................................................................................................................................................................................................................................

   1

5. 1.1

   Synopsis ................................................................................................................................................................................................................................................................................................................................................................................................

   1

6. 1.2

   Accident Scenario ................................................................................................................................................................................................................................................................................................................................................................................................

   2

7. 1.3

   Amtrak ................................................................................................................................................................................................................................................................................................................................................................................................

   5

8. 1.4

   Analysis of the Engineer’s Actions ................................................................................................................................................................................................................................................................................................................................................................................................

   6

9. 1.4.1

   Loss of Situational Awareness ................................................................................................................................................................................................................................................................................................................................................................................................

   9

10. 1.4.2

    Need for Improved Crew Training and Advanced Technologies ................................................................................................................................................................................................................................................................................................................................................................................................

    11

11. 1.5

    Signal and Train Control Information ................................................................................................................................................................................................................................................................................................................................................................................................

    13

12. 1.5.1

    Positive Train Control ................................................................................................................................................................................................................................................................................................................................................................................................

    14

13. 1.5.2

    Two-Person Crews ................................................................................................................................................................................................................................................................................................................................................................................................

    17

14. 1.6

    Train Information ................................................................................................................................................................................................................................................................................................................................................................................................

    20

15. 1.6.1

    Postaccident Testing ................................................................................................................................................................................................................................................................................................................................................................................................

    21

16. 1.7

    Personnel Information ................................................................................................................................................................................................................................................................................................................................................................................................

    21

17. 1.8

    Survival Factors ................................................................................................................................................................................................................................................................................................................................................................................................

    22

18. 1.8.1

    The Derailment Sequence ................................................................................................................................................................................................................................................................................................................................................................................................

    22

19. 1.8.2

    Damage to Passenger Car Windows and Injuries ................................................................................................................................................................................................................................................................................................................................................................................................

    23

20. 1.8.3

    Occupant Protection in Derailment Scenarios ................................................................................................................................................................................................................................................................................................................................................................................................

    26

21. 1.9

    Emergency Medical Response ................................................................................................................................................................................................................................................................................................................................................................................................

    28

22. 1.9.1

    Incident Management ................................................................................................................................................................................................................................................................................................................................................................................................

    28

23. 1.9.2

    Transportation of the Injured ................................................................................................................................................................................................................................................................................................................................................................................................

    29

24. 1.9.3

    Amtrak’s Passenger Accountability System ................................................................................................................................................................................................................................................................................................................................................................................................

    36

25. 1.10

    Factors Not Contributing to This Accident ................................................................................................................................................................................................................................................................................................................................................................................................

    37

26. 2

    Postaccident Actions ................................................................................................................................................................................................................................................................................................................................................................................................

    38

27. 2.1

    NTSB Recommendations ................................................................................................................................................................................................................................................................................................................................................................................................

    38

28. 2.2

    FRA Emergency Order ................................................................................................................................................................................................................................................................................................................................................................................................

    40

29. 2.3

    Amtrak ................................................................................................................................................................................................................................................................................................................................................................................................

    41

30. 3

    Conclusions ................................................................................................................................................................................................................................................................................................................................................................................................

    42

31. 3.1

    Findings ................................................................................................................................................................................................................................................................................................................................................................................................

    42

32. 3.2

    Probable Cause ................................................................................................................................................................................................................................................................................................................................................................................................

    44

33. 4

    Recommendations ................................................................................................................................................................................................................................................................................................................................................................................................

    45

34. 4.1

    New Recommendations ................................................................................................................................................................................................................................................................................................................................................................................................

    45

35. 4.2

    Previously Issued Recommendations Arising from this Accident ................................................................................................................................................................................................................................................................................................................................................................................................

    46

36. 4.3

    Previously Issued Recommendation Reiterated in this Report ................................................................................................................................................................................................................................................................................................................................................................................................

    47

37. 4.4

    Previously-Issued Recommendations Classified in this Report ................................................................................................................................................................................................................................................................................................................................................................................................

    48