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Safety Recommendation Details

Safety Recommendation R-16-036
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: When the research specified in Safety Recommendation R-16-35 identifies safety improvements, use the findings to develop occupant protection standards for passenger railcars to mitigate passenger injuries likely to occur during derailments and overturns.
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: 9/30/2019
Response: Reiterated in the Railroad Accident Report RAR-19-02: Amtrak Passenger Train Head-on Collision With Stationary CSX Freight Train Cayce, South Carolina, February 4, 2018, adopted Jul 23, 2019, published on September 30, 2019, notation number 59351 and accident number RRD18MR003. The attached letter from the NTSB Chairman provides information about the NTSB’s July 23, 2019, report Amtrak Passenger Train Head-on Collision With Stationary CSX Freight Train, Cayce, South Carolina, February 4, 2018, NTSB/RAR-19/02. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (for example, R-16-35). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply exceeds 20 megabytes, including attachments, please e mail us at the same address for instructions on how to send larger documents. Please do not submit both an electronic copy and a hard copy of the same response. This letter provides information about our July 23, 2019, report Amtrak Passenger Train Head-on Collision With Stationary CSX Freight Train, Cayce, South Carolina, February 4, 2018, NTSB/RAR-19/02. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. As a result of this investigation, we identified the following safety issues: • The medical examination process for railroad employees. • The actions and responsibilities of the train crew handling switches. • The CSX Transportation efficiency testing program and staffing. • Operations during signal suspensions. • Implementation of a safety management system by Amtrak (National Railroad Passenger Corporation) to assess and mitigate risks for operation on host railroads. • Occupant protection in passenger railcars. Accordingly, the NTSB reiterates the following safety recommendations to the Federal Railroad Administration. Additional information regarding these reiterations can be found in the noted sections of the report. • Conduct research to evaluate the causes of passenger injuries in passenger railcar derailments and overturns and evaluate potential methods for mitigating those injuries, such as installing seat belts in railcars and securing potential projectiles. (R-16-35) (See section 2.2.2.) • When the research specified in Safety Recommendation R-16-35 identifies safety improvements, use the findings to develop occupant protection standards for passenger railcars that will mitigate passenger injuries likely to occur during derailments and overturns. (R-16-36) (See section 2.2.2.) • Enact Title 49 Code of Federal Regulations Part 270, System Safety Program, without further delay. (R-17-17) (See section 2.8.) • Require railroads to develop a device or technique to eliminate the possibility of employees failing to perform critical tasks such as lining a switch, lining a derail, or ensuring cars are in the clear. (R-18-10) (See section 2.5.) In the same report, we also classified two previously issued safety recommendations: • Issue an Emergency Order directing railroads to require that when signal suspensions are in effect and a switch has been reported relined for a main track, the next train or locomotive to pass the location must approach the switch location at restricted speed. After the switch position is verified, the train crew must report to the dispatcher that the switch is correctly lined for the main track before trains are permitted to operate at maximum authorized speed. (R-18-5), (classified “Closed––Unacceptable Action” in section 2.5.) • Require railroads to develop a device or technique to eliminate the possibility of employees failing to perform critical tasks such as lining a switch, lining a derail, or ensuring cars are in the clear. (R-18-10), (classified “Open––Unacceptable Response” in section 2.5.) The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (for example, R-16-35). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply, including attachments, exceeds 20 megabytes, please e mail us at the same address for instructions on how to send larger documents. Please do not submit both an electronic copy and a hard copy of the same response. 2.2.2 Passenger Injury Mitigation – Occupant Protection Overall, 90 of the 149 (60.4 percent) occupants of Amtrak train P91 were injured in this accident.39 Both crewmembers on the locomotive died. Those ticketed in coach seats were more likely to seek immediate medical attention than those in roomettes or bedrooms (about 80 percent of those in coach seats were injured). None of the passengers ticketed in roomettes or bedrooms was seriously injured (about 17 percent were injured), but one seriously injured crewmember reported being thrown from an upper bunk. According to many passenger reports documented in the medical records, the seated occupants were thrown out of their seats during the crash sequence. The majority of injuries (lacerations and contusions) were to the face, head, and knees, or shins. Two people had broken teeth, one had a broken nose, and one had a facial fracture. Of those seriously injured, three reported falling against the edge of a table, and one reported falling out of an upper bunk. In this accident, the occupants experienced primarily forward motion as the train derailed and came to a standstill. All of the cars remained upright, and there was relatively little damage to the passenger cars themselves. Still, the majority of train car occupants were injured, eight of them seriously. At least three of those seriously injured struck the edges of tables. The majority of the injured were those ticketed in coach seats rather than in roomettes or bedrooms; although “compartmentalized,” they were thrown forward against the structures in front of them with enough force to cause significant head and facial injuries. The NTSB concludes that the majority of passenger injuries resulted from the passengers being thrown from their seats when the trains collided and derailed. Title 49 CFR Part 238 contains the current safety requirements for passenger railroad equipment. Those regulations include standards intended to minimize the effects of collision crash forces by trying to ensure that occupant space is preserved (structural crashworthiness) and that interior fittings such as seats remain secure (interior crashworthiness). To study these standards, the FRA has sponsored full-scale collision testing with conventional and crash energy management equipment (FRA 2002, 2003, 2009). This research for passenger car crashworthiness has focused on in-line collision scenarios and the occupant response to the initial collision impact. In this accident, the passenger cars largely met the objectives of preserved space and secure seats. However, this was not enough to prevent significant injuries and indicates that the effects of derailments on passenger safety have not been sufficiently addressed. Passenger equipment safety regulations did not exist prior to 1999, and the NTSB acknowledges the progress in passenger car design that has been made in the past two decades. These safety standards, however, should not remain static because they may not provide sufficient protection to prevent injuries to occupants in survivable derailments such as this one. The NTSB notes that in the case of highway vehicles, occupant protection standards have evolved to reflect current knowledge of crash dynamics. For example, the NTSB has recognized that in the case of school buses, compartmentalization is an incomplete solution, and seat belts provide an additional layer of injury prevention, especially in lateral impacts and rollovers (NTSB 2013).40 In commercial aviation, energy-absorbing seats and collapsing seat backs are required to meet safety standards. The effectiveness of aviation occupant protection standards has been demonstrated by the fact that over the last decade only one belted passenger was fatally injured in an airline crash in the United States. Therefore, the NTSB concludes that although the passenger equipment safety standards in Title 49 CFR Part 238 provide some level of protection for occupants, the current requirements are not adequate. The NTSB came to a similar conclusion following its investigation of the derailment of Amtrak train 188 in Philadelphia in 2015 (NTSB 2016). As a result of the Philadelphia accident, the NTSB issued two recommendations to the FRA addressing improvements needed to the FRA’s occupant protection standards. Conduct research to evaluate the causes of passenger injuries in passenger railcar derailments and overturns and evaluate potential methods for mitigating those injuries, such as installing seat belts in railcars and securing potential projectiles. (R-16-35) When the research specified in Safety Recommendation R-16-35 identifies safety improvements, use the findings to develop occupant protection standards for passenger railcars that will mitigate passenger injuries likely to occur during derailments and overturns. (R-16-36) The FRA responded to these recommendations in a letter on August 23, 2017, indicating that through its RSAC Passenger Safety Working Group (PSWG), it had continually supported numerous research activities evaluating the causes of passenger injuries in various train derailment and collision scenarios. The FRA went on to say it believed that, unlike accidents in the automobile and air transportation modes, adding seat belts in passenger cars was not an effective way to increase safety because the purpose of seat belts was to allow occupants to survive the deceleration of the vehicle they are in. According to the FRA, passenger rail coach peak deceleration is one-fourth that of automobiles during a collision, and therefore the interior of a typical passenger rail coach provides a level of protection to passengers, at least as effective as the protection provided to automobile and air transport passengers, without the need for seat belts. In addition, the FRA stated that it had extensively evaluated the effectiveness and practicality of available occupant protections, such as seat belts, and concluded that focusing efforts on passenger containment and interior attachment integrity and ensuring that passengers survive secondary impacts were the most effective methods of preventing and mitigating passenger injuries. The FRA indicated that it would continue to support and perform research to evaluate the causes of passenger injuries in train derailments and collisions as specific issues arise, but it did not plan to initiate a separate new research program. Finally, in the same letter, the FRA went on to assert that “the interior of a typical passenger rail coach can provide a level of protection to passengers, without active restraints, at least as effective in preventing fatality as the protection provided to automobile and air transport passengers.” In the Cayce collision, the available level of protection did prevent fatalities from occurring in the passenger coaches but did not prevent serious injuries or mitigate significant “minor” injuries, particularly to passengers’ faces. Required design and operational standards in passenger airplanes, such as collapsible seat backs that limit potential head injuries, minimize the risk of these injuries in an airplane that comes to a sudden stop in a low-velocity incident while landing. The NTSB believes preventing fatalities is not the only goal of occupant protection, and potential solutions are not limited to restraints. The NTSB found similar issues in the investigation of the accident in DuPont, Washington. In that report, Safety Recommendations R-16-35 and -36 were reiterated and classified Open?Unacceptable Response. The injuries in the Cayce accident further demonstrate the need for improved occupant protection in rail, and as a result the NTSB reiterates Safety Recommendations R-16-35 and R-16-36.

From: FRA
To: NTSB
Date: 9/27/2019
Response: -From Ronald L. Batory, Administrator: This letter is the Federal Railroad Administration's (FRA) response to the National Transportation Safety Board's (NTSB) Safety Recommendations R-19-008 through-015 and reiterations of R-16-32, R-16-35, R-16-36, and R-17-17. The NTSB issued and reiterated these safety recommendations, respectively, after its investigation of the December 18, 2017, derailment of National Railroad Passenger Corporation (Amtrak) train 501 in DuPont, Washington. Based on FRA's investigation, FRA maintains the primary cause of the Amtrak 501 derailment was the failure of the engineer and the conductor to comply with Amtrak's operating rules. Specifically, the engineer failed to prioritize attention and situational awareness to properly call out speeds and identify the wayside signals and signs. FRA also maintains that improper crewmember training was a contributing accident cause, as FRA's investigation found training for the assigned crewmembers of Amtrak 501 did not comply with Federal regulations. With these factors in mind, please find below FRA's specific responses to each safety recommendation. In the same letter sent August 23, 2017, regarding Safety Recommendation R-16-35, FRA informed the NTSB that its RSAC process remains the primary mechanism for FRA to discuss and develop Federal regulations related to passenger equipment safety issues. Specifically, FRA stated that in 2009, RSAC's Passenger Safety Working Group created the Engineering Task Force to further examine issues and research topics concerning passenger equipment safety, including occupant protection. These efforts subsequently led FRA to amend its Passenger Equipment Safety Standards in November 2018 using a performance-based approach to adopt new and modified requirements governing the construction of conventional- and high-speed passenger rail equipment. 18 FRA will continue to use RSAC to address the regulatory needs of passenger railcar safety and continues to believe its actions have addressed this recommendation, notwithstanding the NTSB's letter to FRA dated June 21, 2019, in which the NTSB reiterated this recommendation and reclassified it as "Open-Unacceptable Response." FRA therefore will take no further action in response to Safety Recommendation R-16-36 and requests that the NTSB close the recommendation.

From: NTSB
To: FRA
Date: 6/24/2019
Response: Reiterated 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: NTSB
To: FRA
Date: 6/24/2019
Response: Reiterated 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. On May 12, 2015, less than 2 years after the Metro-North derailment, Amtrak train 188 derailed near Philadelphia, Pennsylvania (NTSB 2016). Four passengers were ejected and killed. The NTSB accident report discussed the FRA’s current passenger equipment safety regulations, which did not require protection from lateral forces caused by derailments and overturns. The injuries in the Amtrak train 188 accident illustrated the need for railcar safety design standards to address such forces. The NTSB’s report about the Amtrak train 188 accident concluded that, although the passenger equipment safety standards in 49 CFR Part 238 provide some level of protection for occupants, the current requirements did not ensure that occupants are protected in some types of accidents, and that railroad occupant safety research and regulations should better reflect the different types of accidents that were occurring and employ a systematic approach that considers the causes of injury during derailments in which occupants may be thrown or struck by loose objects. As a result, the NTSB issued two recommendations to the FRA addressing improvements needed to the FRA’s occupant protection standards: Conduct research to evaluate the causes of passenger injuries in passenger railcar derailments and overturns and evaluate potential methods for mitigating those injuries, such as installing seat belts in railcars and securing potential projectiles. (R-16-35) When the research specified in Safety Recommendation R-16-35 identifies safety improvements, use the findings to develop occupant protection standards for passenger railcars that will mitigate passenger injuries likely to occur during derailments and overturns. (R-16-36) The FRA responded to these recommendations on August 23, 2017, indicating that through its Rail Safety Advisory Committee (RSAC) Passenger Safety Working Group, it had continually supported numerous research activities evaluating the causes of passenger injuries in various train derailment and collision scenarios. The FRA said that its effort supported new industry standards and federal regulation where necessary, including a notice of proposed rulemaking (NPRM) updating and supplementing its passenger equipment safety standards. The FRA went on to discuss its belief that, unlike accidents in the automobile and air transportation modes, adding seat belts in passenger railcars was not an effective way to increase safety because the purpose of seat belts was to allow occupants to survive the deceleration of the volume within which they are contained. According to the FRA, passenger rail coaches experience a peak deceleration of one-fourth that of automobiles during a collision and, therefore, the interior of a typical passenger railcar provides a level of protection to passengers, without the need for seat belts, at least as effective as the protection provided to automobile and air transport passengers. The FRA also wrote in its August 23, 2017, letter, that it had extensively evaluated the effectiveness and practicality of available occupant protections such as seat belts, and it concluded that focusing efforts on passenger containment and interior attachment integrity, and ensuring that passengers survive secondary impacts, were the most effective methods of preventing and mitigating passenger injuries. The FRA indicated that it would continue to support and perform research to evaluate the causes of passenger injuries in train derailments and collisions as specific issues arise, but it did not plan to initiate a separate new research program. The NTSB does not agree with the FRA that its current research program and regulations effectively address protecting passengers in railcars involved in derailments and overturns. In the span of 4 years, the NTSB has investigated three major railroad accidents involving passenger railcar derailments that resulted in significant lateral acceleration, for which containment did not adequately protect the 11 passengers killed after being ejected from the railcars. In addition, containment did not fully protect the over 300 passengers hospitalized in these accidents. The NTSB concludes that this accident shows the need for the FRA to take action on Safety Recommendations R-16-35 and -36, which addressed the FRA’s occupant protection standards. Therefore, the NTSB reiterates Safety Recommendations R-16-35 and -36 to the FRA, which are reclassified OPEN—UNACCEPTABLE RESPONSE.

From: FRA
To: NTSB
Date: 8/23/2017
Response: -From Heath Hall, Acting Administrator: This reply is in response to the National Transportation Safety Board's (NTSB) June 9, 2016, letter to the Federal Railroad Administration (FRA) regarding the NTSB 's Safety Recommendations R-16-35 and R-16-36. Enclosed is FRA's response to these recommendations. FRA believes its ongoing efforts to improve passenger safety address the specific directives in these recommendations. Therefore, FRA respectfully requests NTSB classify Safety Recommendations R-16-35 and R-16-36 as, "Closed-Acceptable Response." FRA plans to continue its long history developing occupant protection standards based on research. FRA has continuously relied on both industry and internal research to form the basis of its passenger safety rulemakings since first issuing the initial Passenger Equipment Safety Standards in 1999. 5 Every passenger equipment safety rulemaking since has incorporated findings from occupant protection research, most notably in the areas of crash energy management and interior fittings and attachments. As noted above, FRA's most recent passenger equipment NPRM6 continues to build on this research for minimizing the risk of hazardous projectiles and other occupant protection requirements. Specifically, FRA's RSAC has been instrumental in developing passenger equipment safety standards based on research. On May 20, 2003, FRA presented the RSAC with the task of reviewing passenger equipment safety needs and programs to provide recommendations on actions that could be taken to advance the safety of passenger rail service. In response, RSAC formed the Passenger Safety Working Group, which consists of many of the same entities and representatives present in the full RSAC, but also provides industry expertise in areas specific to passenger rail safety. In 2009, the Working Group created the Engineering Task Force (ETF) to further examine issues and research topics concerning passenger equipment safety, including occupant protection. The ETF's development of recommendations for regulatory actions is ongoing. The RSAC process remains the primary mechanism for FRA to discuss and develop Federal regulations related to passenger equipment safety issues. FRA will continue to use the RSAC Working Group and ETF to address the regulatory needs of passenger railcar occupant protection, including any necessary safety improvements consistent with the intent of this safety recommendation.

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.