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Safety Recommendation Details

Safety Recommendation R-16-032
Details
Synopsis: About 9:21 p.m. eastern daylight time on May 12, 2015, eastbound Amtrak (National Railroad Passenger Corporation) passenger train 188 derailed at milepost 81.62 in Philadelphia, Pennsylvania. The train had just entered the Frankford Junction curve—where the speed is restricted to 50 mph—at 106 mph. It was dark and 81°F with no precipitation; visibility was 10 miles. As the train entered the curve, the locomotive engineer applied the emergency brakes. Seconds later, the train—one locomotive and seven passenger cars—derailed. There were 245 passengers, 5 on-duty Amtrak employees, and 3 off-duty Amtrak employees on board. Eight passengers were killed, and 185 others were transported to area hospitals. 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.
Recommendation: TO THE FEDERAL RAILROAD ADMINISTRATION: Require railroads to install devices and develop procedures that will help crewmembers identify their current location and display their upcoming route in territories where positive train control will not be implemented.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Railroad
Location: Philadelphia, PA, United States
Is Reiterated: Yes
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: 6/9/2016
Date Closed:
Addressee(s) and Addressee Status: FRA (Open - Unacceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FRA
Date: 6/24/2019
Response: Reiterated and reclassified in the Railroad Accident Report RAR-19-01: Amtrak Passenger Train 501 Derailment DuPont, Washington December 18, 2017, Adopted on May 21, 2019 and published on June 24, 2019, notation number 58913 and accident number RRD18MR001. The NTSB’s May 12, 2015, accident report regarding the derailment of Amtrak train 188 near Philadelphia, Pennsylvania, discussed possible technologies that could, when PTC was not available, effectively mitigate hazards associated with engineers becoming spatially disoriented (NTSB 2016). In the Philadelphia accident, the engineer overlooked the speed restriction of an upcoming curve and derailed the train. There are similarities between the DuPont and Philadelphia accidents regarding engineers failing to recognize an upcoming curve and associated speed restrictions. In both accidents there was no active PTC in place and the physical cues for the engineers were not significant enough to alert them of the upcoming speed restriction. In the Philadelphia report, the NTSB stated, “the engineer likely would have benefitted from technology that showed him the location of his train in real time, which would have also helped him establish and maintain his situational awareness.” As a result, the NTSB issued the following Safety Recommendation to the FRA: Require railroads to install devices and develop procedures that will help crewmembers identify their current location and display their upcoming route in territories where positive train control will not be implemented. (R-16-32) The FRA’s initial response (February 9, 2018) suggested that this recommendation required the development and testing of new technologies before it could evaluate its implementation. In order to move forward on the recommendation, the FRA planned to determine the following: • The level of interest within the community • If the technology would improve safety • The cost (inclusive of other resources) necessary for deployment • The potential benefits relative to the societal costs On March 28, 2019, the FRA wrote that it discussed the recommendation with the Class I railroads who believed that the technology needed to satisfy the recommendation was not available, and that they did not intend to develop it. The FRA also asserted that 49 CFR Parts 240 and 242 already require locomotive engineers and conductors to be familiar with the physical characteristics of the territories in which they work. Under these regulations, the FRA initiated multiregional audits of the railroads, focusing on operations in nonsignaled territory. The FRA concluded its March 28, 2019, letter saying that the need for Safety Recommendation R-16-32 was “dubious” and the costs would “certainly be tremendous, costing at least in the hundreds of millions of dollars . . ..” Given that the technology does not exist, that it had “little to no known safety benefits” to offset its significant cost, and that a regulation requiring railroads to install the technology would be redundant with existing rules, the FRA did not plan to take the recommended action. In issuing Safety Recommendation R-16-32, the NTSB believed that the recommended technology was readily available and affordable. Moving map displays that use global positioning systems (GPS) are commonly available in personal cell phones and tablets used by many people. As a result, the NTSB is concerned that both the FRA and the Class I railroads that reviewed the recommendation did not fully understand it. Amtrak briefed NTSB investigators on May 20, 2019, on their recent development of a moving map display designed to enhance situational awareness of the train crews on their route. The application, called AWARE, monitors the position and speed of a train in real-time. Amtrak demonstrated a proof of concept in November 2018 and is working on a targeted deployment of the application on territory with a Positive Train Control Mainline Track Exclusion Addendum (MTEA) in 2019 with system-wide deployment to follow. The NTSB believes that this recommendation is applicable to the DuPont accident. In both the Philadelphia accident and the DuPont accident, experienced engineers who were in compliance with 49 CFR Part 240 became disoriented. In the Philadelphia accident, a qualified and experienced engineer became spatially disoriented when his attention was diverted. The engineer in the DuPont accident knew of the speed restriction, but because he was not familiar with the territory and the approaching speed restriction, he failed to slow the train. Other human factors considerations, such as poor visibility or unexpectedly high workload, can also contribute to an engineer becoming spatially disoriented. The NTSB now understands that using readily available, low-cost technology, such as GPS and moving map displays, is a potential technology solution that the FRA did not consider. The NTSB believes that, in both the Philadelphia and DuPont accidents, this technology would have likely helped both engineers remain spatially oriented. Although the FRA and Class I railroads believe that the required technology is not available and would be expensive to develop, and that 49 CFR Parts 240 and 242 fully address the safety issue, despite our findings, the NTSB asks that the FRA reconsider this decision in view of the availability and cost of the actual recommended technology. The NTSB concludes that because the FRA did not act on the recommendation to add technology to assist engineers in determining their location, an opportunity to improve safety was overlooked. Consequently, Safety Recommendation R-16-32 is reiterated and is classified OPEN—UNACCEPTABLE RESPONSE.

From: NTSB
To: FRA
Date: 6/24/2019
Response: Reiterated and reclassified in the Railroad Accident Report RAR-19-01: Amtrak Passenger Train 501 Derailment DuPont, Washington December 18, 2017, Adopted on May 21, 2019 and published on June 24, 2019, notation number 58913 and accident number RRD18MR001.

From: FRA
To: NTSB
Date: 3/28/2019
Response: -From Ronald L. Batory, Administrator: On February 9, 2018, FRA responded to the NTSB, explaining our plan of action and stating that this recommendation requires developing and testing new technologies-and their associated processes-before considering implementation. Further, FRA indicated its intent to determine: • The level of interest within the community; • If the technology would improve safety; • The cost (inclusive of other resources) necessary for deployment; and • The potential benefits relative to the societal costs. If our outreach and review supported moving forward, we would determine options for implementing the technology. On May 9, 2018, the NTSB classified this recommendation as "Open-Acceptable Response." FRA discussed this recommendation with the Class I railroads, who made it clear that the technology needed to meet the intent of this recommendation is not available and they did not intend to pursue such technology in the future. However, in territories where positive train control (PTC) will not be implemented, Class I railroads have largely installed or have plans to install Trip Optimizer programs that provide some positioning and route information. Although a railroad's voluntary step to install Trip Optimizer would not fully address this recommendation, such effort should be recognized as a substantial investment1 that is providing some geographical track configuration data to the locomotive engineer - albeit with the goal of improving fuel efficiency, not safety. The voluntary installation of Trip Optimizer programs is viewed by railroads as a stepping stone toward a more automated and technologically integrated rail operation system that will likely, in time, lead to the voluntary installation of PTC systems on routes not legally mandated. The Class I railroads do not believe implementing this recommendation will reduce the likelihood of future accidents, as there are existing Federal requirements covering the subject. Title 49 Code of Federal Regulations Parts 240 and 242 require locomotive engineers and conductors be familiar with the physical characteristics of the territories in which they will be working. To ensure compliance with these regulations, FRA has initiated headquarters-led, multi-regional audits of the railroads with a focus on operations in non-signaled territory. Although FRA is not suggesting that more visible territorial information through technology would detract from safety, the need for it is dubious and the costs would certainly be tremendous, costing at least in the hundreds of millions of dollars if Trip Optimizer is used as a basis of comparison. In fact, because such technology does not yet exist, the costs for research, development and implementation would likely exceed the Trip Optimizer installation cost estimates. For these reasons, measures required to meet the intent of this recommendation cannot be justified under existing Office of Management and Budget strictures regarding the estimated costs vis-a-vis the expected benefits (i.e. accidents averted). Given that the technology does not exist, that it has little to no known safety benefits to offset its significant cost, and that a regulation requiring railroads to install the technology would be redundant with existing rules, FRA will not take any further action. FRA respectfully asks the NTSB to close Safety Recommendation R-16-32. I appreciate your interest in these important safety issues. If FRA can provide more information or assistance, please contact Mr. Robert C. Lauby, Associate Administrator for Railroad Safety and Chief Safety Officer.

From: NTSB
To: FRA
Date: 5/9/2018
Response: We note that, prior to implementing this safety recommendation, you will consult with the railroads under your regulatory authority to ascertain if the appropriate technology is available or being developed, and if it will improve safety. Further, you will analyze the cost and benefit associated with implementing this recommendation. We suggest that you also seek guidance from railroad operators outside your regulatory authority and from other entities, such as Volpe, as you consider potential methods of satisfying this recommendation. Pending your development of a requirement that railroads install devices and procedures to help crewmembers, as recommended, Safety Recommendation R-16-32 is classified OPEN--ACCEPTABLE RESPONSE.

From: FRA
To: NTSB
Date: 2/9/2018
Response: -From Juan D. Reyes III, Chief Counsel: FRA believes that addressing this recommendation will require developing and testing new or adapted technologies, as well as their associated processes and procedures, before FRA can consider implementation. These efforts will be necessary for FRA to determine: • The level of interest within the regulated community; • If the technology referred to in the recommendation will improve safety; • The cost and other resources necessary for various deployment scenarios; and • The potential safety benefits relative to the societal costs. FRA is currently working to identify potential grantees who could assist in answering these foundational research questions. If the research supports moving forward, then FRA can begin determining options for implementing the technology. FRA respectfully asks NTSB to accept our proposed course of action, and reclassify this recommendation from "Open- Await Response" to "Open-Acceptable Response." I appreciate your interest in this important safety issue. If FRA can provide further information or assistance, please contact Mr. Robert C. Lauby, Associate Administrator for Railroad Safety and Chief Safety Officer.

From: NTSB
To: FRA
Date: 6/9/2017
Response: On May 17, 2016, the National Transportation Safety Board (NTSB) adopted its report concerning the May 12, 2015, accident in which Amtrak passenger train 188 derailed in Philadelphia, Pennsylvania.1 Additional information about this accident and the resulting recommendations may be found in the report of the investigation, which can be accessed at our website, http://www.ntsb.gov, under report number RAR-16/02. As a result of this investigation, we reiterated Safety Recommendation R-14-74 to the Federal Railroad Administration; reclassified Safety Recommendations R-15-28, R-15-29, and R-15-30 to Amtrak; closed Safety Recommendation R-13-23 to the Federal Railroad Administration; and issued 11 new safety recommendations, including one to Amtrak; one to the American Public Transportation Association and the Association of American Railroads; two to the Philadelphia Police Department, the Philadelphia Fire Department, and the Philadelphia Office of Emergency Management; one to the mayor of Philadelphia; one to the National Association of State EMS 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; and the following five recommendations to the Federal Railroad Administration.