- Transportation of the injured after mass casualty incidents. The NTSB found that, as a result of victims being transported to hospitals without coordination, some hospitals were over utilized while others were significantly underutilized during the response to the derailment. The NTSB further found that current Philadelphia Police Department, Philadelphia Fire Department, and Philadelphia Office of Emergency Management policies and procedures regarding transportation of patients in a mass casualty incident need to be better coordinated.
The NTSB determines that the probable cause of the accident was the engineer's acceleration to 106 mph as he entered a curve with a 50 mph speed restriction, due to his loss of situational awareness likely because his attention was diverted to an emergency situation with another train. Contributing to the accident was the lack of a positive train control system. Contributing to the severity of the injuries were the inadequate requirements for occupant protection in the event of a train overturning.
As a result of this investigation, the NTSB 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.
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