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Safety Recommendation Details

Safety Recommendation R-15-029
Details
Synopsis: About 9:21 p.m. on May 12, 2015, National Railroad Passenger Corporation (Amtrak) passenger train 188 derailed at milepost 81.62 near Frankfort Junction in Philadelphia, Pennsylvania. The tracks in the area of the derailment have a 4-degree curve with a permanent speed restriction of 50 mph. Event recorder data indicated the train was traveling 106 mph when the engineer made an emergency brake application; soon afterward, the train derailed at the curve. There were 250 passengers and 8 Amtrak employees on board. Eight passengers died, and more than 200 passengers were treated for injuries.
Recommendation: TO THE NATIONAL RAILROAD PASSENGER CORPORATION (AMTRAK): Semi-annually, issue a public report detailing Amtrak’s progress in installing crash-and fire-protected inward-and outward-facing audio and image recorders. The report should include the number of locomotives and cab car operating compartments that have been equipped with the recorders, as well as the number of locomotives and cab car operating compartments in Amtrak’s fleet that still lack those devices.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Railroad
Location: Philadelphia, PA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA15MR010
Accident Reports: Preliminary Report: Railroad ​DCA15MR010Derailment of Amtrak Passenger Train 188
Report #: RAR-16-02
Accident Date: 5/12/2015
Issue Date: 7/8/2015
Date Closed:
Addressee(s) and Addressee Status: Amtrak (National Railroad Passenger Corporation) (Open - Acceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 9/12/2018
Response: We note that you have experienced performance issues and delivery delays with your vendor for the prototype that synchronizes audio, video, and event recorders. Although we are encouraged to learn that, as of December 2017, you installed inward-facing audio and image recorders on 63 Amtrak Cities Sprinter (ACS) locomotives, you did not state if this number represents your entire ACS fleet, including those locomotives temporarily out of service for repair or maintenance, nor did you specify the number of locomotives and cab cars on order that will be equipped with the recommended technology from the manufacturer. Further, you did not tell us how many cab car operating compartments have been equipped with recorders and how many still lack them. Pending our receipt of this information, Safety Recommendation R 15-29 remains classified OPEN--ACCEPTABLE RESPONSE.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 7/6/2018
Response: -From Kenneth J. Hylander, Executive Vice President and Chief Safety Officer: Amtrak currently has 104 locomotives equipped with outward and inward facing cameras. Since 2007, Amtrak has installed outward-facing audio and image recorders on Amtrak owned controlling locomotive cabs and cab cars. Beginning in 2015, Amtrak installed stand-alone inward facing Locomotive Digital Recording Systems - Video (LDRS-V) for audio and digital video on all active ACS-64 Locomotives operating on the Northeast Corridor (NEC). Amtrak has exchanged its previously installed LDRS-V with upgraded LDRS-V's to provide 12hr recording capacity and synchronization of both inward and outward video/audio recordings with the event recorder on ACS-64 units. Amtrak completed the exchange of all ACS-64 LDRS-V units to support the Inward and Outward camera recording synchronization. 35 of 40 Acela trainset power cars are complete and an additional 3 power cars are partially complete. Completion of the Acela trainsets is on target for completion by Dec 2018 or earlier. Installations for all other fleets including the P42 fleet have been postponed pending resolution of a conflict with a secondary system used to remotely connect to the camera system and Event recorder for management and collection of the onboard data. This system utilizes a lx modem which must be upgraded due to pending network obsolescence and inability to support large data files required with the newer increased resolution camera system. Amtrak is quickly working to determine upgrade options of the onboard train communications data hardware to address this issue. Remaining Amtrak fleets will be completed pending resolution of the Train communications onboard hardware upgrade solution and resolution of vendor software performance issues. Amtrak will provide an updated installation schedule based on vendor resolution of technical issues. Amtrak will continue to provide semi-annual progress reports.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 1/25/2018
Response: We appreciate you informing us of the delivery delays associated with your vendor for the new prototype of synchronized audio and video recorders. We are encouraged to learn that you installed inward-facing audio and image recorders on 30 Amtrak Cities Sprinter (ACS) locomotives as of June 2017, but you did not state if this number represents your entire ACS fleet, including those locomotives temporarily out of service for repair or maintenance, nor did you specify how many locomotives and cab cars you have on order will be equipped with the recommended technology from the manufacturer. Further, you did not tell us how many cab car operating compartments have been equipped with recorders and how many still lack them. Pending our receipt of this information, Safety Recommendation R-15-29 is classified OPEN--ACCEPTABLE RESPONSE.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 12/28/2017
Response: -From Richard H. Anderson, President and Chief Executive Officer: Amtrak issued a procurement contract in March 2017 for an LDRS-V system for its remaining active locomotives and cab cars to provide 12-hour crash hardened continuous recorder and the capability of synchronized audio and video recordings with the event recorder. Pending a successful resolution of FAI and prototype issues, Amtrak plans to complete installations on an Acela Power Car and a Genesis-type (P42, P32DM or P40) locomotive in Janua1y 2018. This will facilitate a production release for the majority of the Amtrak fleet. Currently, one P42 unit is complete, and one Acela trainset is complete. Prototype installations will be completed for each vehicle type of other fleets prior to release for production kits. For each equipment type, an initial vehicle installation and training at the location accomplishing the work will be completed and any installation instruction changes incorporated. Amtrak continues working to a target completion of December 2018 despite continued vendor product delive1y and performance issues. The installation schedule will be adjusted and refined after prototype installation and operational functionality issues have been successfully completed. Amtrak began exchanging ACS-64 LDRS-V units in April to support the inward and outward camera recording synchronization. Amtrak has completed 63 of 69 units as of December 2017. Amtrak is dependent on vendor material delive1y schedules, acceptance testing, and installation capacity to meet our aggressive installation target. Amtrak will provide an updated installation schedule based on vendor resolution of technical issues. Amtrak will continue to provide semiannual progress reports.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 7/13/2017
Response: -From C.W. Moorman, President and Chief Executive Officer: Amtrak issued a procurement contract in March 2017 for an LDRS-V system for its remaining active locomotives and cab cars to provide 12-hour crash hardened continuous recorder and the capability of synchronized audio and video recordings with the event recorder. Our previous report in February 2017 indicated installations would begin this May. Due to additional time required to complete design and finalize Installation kit bill of material the F AI has been rescheduled to early August at the vendor's facility. Pending a successful F AI, Amtrak plans to complete prototype installations on an Acela Power Car and a Genesis type (P42, P32DM or P40) locomotive also in August 2017. This will facilitate a production release for the majority of the Amtrak fleet. Prototype installations will be completed for each vehicle type prior to release for production kits. For each equipment type, an initial vehicle installation and training at the location accomplishing the work will be completed and any installation instruction changes incorporated. Amtrak will begin in September to install inward and replace outward facing cameras on all locomotives and cab cars. The installation schedule will be adjusted and refined after prototype installations have been successfully completed. Despite the delay in prototyping, Amtrak remains on schedule to complete the installation of the systems throughout the fleet by December 2018. Amtrak began exchanging ACS-64 LDRS-V units in April to support the Inward and Outward camera recording synchronization. Our previous report indicated a June completion; however, our supplier deliveries are behind schedule and account for the delay in completion. Amtrak has completed 30 of 69 units as of June 2017 and we are working to improve material delivery schedules. Amtrak is dependent on vendor material delivery schedules, acceptance testing, and installation capacity to meet our aggressive installation target. Amtrak will provide an updated installation schedule at our December 2017 repot1 based on the successes of preliminary vehicle installations. Amtrak will continue to provide Semi-annual progress reports.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 5/11/2017
Response: We are pleased to learn that you have installed inward-facing audio and image recorders in 69 out of 70 locomotives, and that you are currently developing an inward- and outward facing camera video and audio recorder system that incorporates the Federal Railroad Administration event recorder into a single, crash-hardened storage device. Please keep us informed of your progress. Pending your next update, Safety Recommendation R 15-29 remains classified OPEN--ACCEPTABLE RESPONSE.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 2/8/2017
Response: -From C.W. Moorman, President and Chief Executive Officer: Installation of inward-facing audio and image recorders was completed on the fleet of 69 out of 70 locomotives, with the 601 currently out of service for repairs. Amtrak is currently in development of an inward- and outward-facing camera video and audio recorder system that incorporates the FRA Event Recorder into a single crash-hardened storage device. This device will also provide the capability of synchronizing the audio/video data and event recorder data on locomotives. In accordance with the October 2016 update, Amtrak has finalized the technical specification for the procurement of materials for its fleets and has initiated the procurement process accordingly. Presently, Amtrak assumes the prospective manufacture of these systems can meet its aggressive installation schedule by completing the installations through CY20 18. The enclosed installation schedule details the order of installations by fleet through December 2018. Amtrak will issue the next installation progress update in June of 2017, with additional repot is being released every six months thereafter. I trust that the information contained within this letter is sufficient to provide a status update on Amtrak's efforts to address the open recommendations noted above.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 10/31/2016
Response: -From C.W. Moorman, President and Chief Executive Officer: Installation of inward-facing audio and image recorders was completed on the fleet of 69 out of 70 locomotives, with the 601 currently out of service for repairs. Amtrak is currently in development of an inward- and outward-facing camera video and audio recorder system that incorporates the FRA Event Recorder into a single crash-hardened storage device. This device will also provide the capability of synchronizing the audio/video data and event recorder data on locomotives. Amtrak plans to finalize the technical specification for the procurement of materials for its fleets in November 2016 and will begin the procurement process accordingly. Presently, Amtrak assumes the prospective manufacture of these systems can meet its aggressive installation schedule by completing the installations through CY20 18. Amtrak will release the full installation schedule in January of 2017 with installation progress reports being released every six months thereafter.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 6/9/2016
Response: Safety Recommendations R-15-28 through R-15-30 were reclassified in NTSB Railroad Accident Report RAR-16-02, concerning the May 12, 2015 accident in which Amtrak passenger train 188 derailed in Philadelphia, Pennsylvania. The engineer’s inability to report what happened in the moments before the accident presented a challenge to investigators. Inward-facing audio and image recorders in the cab would have provided important information in this case—and many others—to assist investigators in understanding what happened. Such cameras are installed on some trains and have assisted the NTSB in recent investigations. As a result, on July 8, 2015, the NTSB issued the following recommendations to Amtrak: R-15-28 Install, in all controlling locomotive cabs and cab car operating compartments, crash- and fire-protected inward-and outward-facing audio and image recorders capable of providing recordings to verify that train crew actions are in accordance with rules and procedures that are essential to safety as well as train operating conditions. The devices should have a minimum 12-hour continuous recording capability with recordings that are easily accessible for review, with appropriate limitations on public release, for the investigation of accidents or for use by management in carrying out efficiency testing and systemwide performance monitoring programs R-15-29 Semi-annually, issue a public report detailing Amtrak’s progress in installing crash- and fire-protected inward- and outward-facing audio and image recorders. The report should include the number of locomotives and cab car operating compartments that have been equipped with the recorders, as well as the number of locomotives and cab car operating compartments in Amtrak’s fleet that still lack those devices R-15-30 Regularly review and use in-cab audio and image recordings in conjunction with other performance data to verify crewmember actions are in accordance with rules and procedures that are essential to safety. In a letter dated March 10, 2016, Amtrak reported that it had installed inward-facing video cameras meeting the specifications in the recommendation on its current fleet of 57 ACS-64 locomotives and that it continues to install them throughout the fleet. Amtrak stated it was planning to install crash-hardened units incorporating event recorders on its fleet and would release another installation progress report in October 2016. Amtrak also stated it had developed a policy for the use of data obtained by inward- and outward-facing audio and image recorders. On the basis of this response, recommendations R-15-28 through -30 are classified OPEN—ACCEPTABLE RESPONSE.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 5/25/2016
Response: We are encouraged to learn that Amtrak installed inward-facing audio and image recorders on 57 ACS-64 locomotives in 2015, but you did not state whether this number represents your entire fleet of these locomotives, including those temporarily out of service for repair or maintenance. In addition to that information, we would like to know how many locomotives and cab cars are currently in the requisition process. Please provide us information for state owned locomotives and cab cars, as well, if Amtrak is, or will be, operating them. Pending our receipt of this information, Safety Recommendation R-15-29 is classified OPEN—ACCEPTABLE RESPONSE.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 3/10/2016
Response: -From Joseph H. Boardman, President and Chief Executive Officer: Installation of inward-facing audio and image recorders was completed on the fifty seven (57) ACS-64 locomotives in 2015. Amtrak is currently in development of an inward- and outward-facing camera video and audio recorder system that incorporates the FRA Event Recorder into a single-crash, hardened storage device. This device also provides the capability of synchronizing the audio/video data and event recorder data on ACS-64 locomotives. Amtrak plans to finalize the technical specification for the procurement of materials for its fleets once the prototype device is accepted. Presently, Amtrak assumes the prospective manufacturer of these devices can meet its aggressive installation schedule by completing seventy (70) ACS-64locomotives in July 2016, followed by the installations on it remaining twenty (20) Acela Trainsets, one hundred ninety-six (196) P-42 locomotives, thirteen (13) P-40 locomotives, sixteen (16) 9600 Series Cab Cars, eighteen (18) P-38-DM locomotives, eighteen (18) P32-8locomotives, twentythree (23) NPCU cars, and eight (8) Surfliner cab cars. It is anticipated that the installations will proceed through CY 2018. This does not include any installations on state-owned locomotives or cab cars. Amtrak will release the next installation progress report in October 2016, with additional releases occurring every six (6) months thereafter.