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

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

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