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NTSB
Railroad Accident Report
Contents
- Figures and Tables................................................................................................................................................................................................................................................................................................................................................................................................
iii - Abbreviations and Acronyms................................................................................................................................................................................................................................................................................................................................................................................................
iv - Executive Summary................................................................................................................................................................................................................................................................................................................................................................................................
vi 1. Investigation and Analysis................................................................................................................................................................................................................................................................................................................................................................................................1 1.1 Synopsis................................................................................................................................................................................................................................................................................................................................................................................................1 1.2 Accident Scenario................................................................................................................................................................................................................................................................................................................................................................................................2 1.3 Amtrak................................................................................................................................................................................................................................................................................................................................................................................................5 1.4 Analysis of the Engineer’s Actions................................................................................................................................................................................................................................................................................................................................................................................................6 1.4.1 Loss of Situational Awareness................................................................................................................................................................................................................................................................................................................................................................................................9 1.4.2 Need for Improved Crew Training and Advanced Technologies................................................................................................................................................................................................................................................................................................................................................................................................11 1.5 Signal and Train Control Information................................................................................................................................................................................................................................................................................................................................................................................................13 1.5.1 Positive Train Control................................................................................................................................................................................................................................................................................................................................................................................................14 1.5.2 Two-Person Crews................................................................................................................................................................................................................................................................................................................................................................................................17 1.6 Train Information................................................................................................................................................................................................................................................................................................................................................................................................20 1.6.1 Postaccident Testing................................................................................................................................................................................................................................................................................................................................................................................................21 1.7 Personnel Information................................................................................................................................................................................................................................................................................................................................................................................................21 1.8 Survival Factors................................................................................................................................................................................................................................................................................................................................................................................................22 1.8.1 The Derailment Sequence................................................................................................................................................................................................................................................................................................................................................................................................22 1.8.2 Damage to Passenger Car Windows and Injuries................................................................................................................................................................................................................................................................................................................................................................................................23 1.8.3 Occupant Protection in Derailment Scenarios................................................................................................................................................................................................................................................................................................................................................................................................26 1.9 Emergency Medical Response................................................................................................................................................................................................................................................................................................................................................................................................28 1.9.1 Incident Management................................................................................................................................................................................................................................................................................................................................................................................................28 1.9.2 Transportation of the Injured................................................................................................................................................................................................................................................................................................................................................................................................29 1.9.3 Amtrak’s Passenger Accountability System................................................................................................................................................................................................................................................................................................................................................................................................36 1.10 Factors Not Contributing to This Accident................................................................................................................................................................................................................................................................................................................................................................................................37 2 Postaccident Actions................................................................................................................................................................................................................................................................................................................................................................................................38 2.1 NTSB Recommendations................................................................................................................................................................................................................................................................................................................................................................................................38 2.2 FRA Emergency Order................................................................................................................................................................................................................................................................................................................................................................................................40 2.3 Amtrak................................................................................................................................................................................................................................................................................................................................................................................................41 3 Conclusions................................................................................................................................................................................................................................................................................................................................................................................................42 3.1 Findings................................................................................................................................................................................................................................................................................................................................................................................................42 3.2 Probable Cause................................................................................................................................................................................................................................................................................................................................................................................................44 4 Recommendations................................................................................................................................................................................................................................................................................................................................................................................................45 4.1 New Recommendations................................................................................................................................................................................................................................................................................................................................................................................................45 4.2 Previously Issued Recommendations Arising from this Accident................................................................................................................................................................................................................................................................................................................................................................................................46 4.3 Previously Issued Recommendation Reiterated in this Report................................................................................................................................................................................................................................................................................................................................................................................................47 4.4 Previously-Issued Recommendations Classified in this Report................................................................................................................................................................................................................................................................................................................................................................................................48
i