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Safety Recommendation Details

Safety Recommendation R-16-037
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 NATIONAL RAILROAD PASSENGER CORPORATION (AMTRAK): Incorporate strategies into your initial and recurrent training for operating crewmembers for recognizing and effectively managing multiple concurrent tasks in prolonged, atypical situations to sustain their attention on current and upcoming train operations.
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: 6/9/2016
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 are addressing this recommendation by contracting with an expert in human attention to assess the potential causes of attention-related errors, and you are creating scenarios with operational challenges and unexpected circumstances that locomotive engineers may face in everyday operations. Please keep us informed as this project advances. Pending our receipt and evaluation of your results, Safety Recommendation R-16-37 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 contracted with the Atticus Consulting Group LLC, {'Atticus') a leading expert in the science of human attention, to conduct an assessment of the potential causes of attention-related errors in its train operations and to initiate a pilot project to provide attention performance training to its Washington based train engineers. This pilot project is referred to as the "Distraction, Affect and Attention Workplace Assessment {DA3)" and "Attention Performance Training for Amtrak Engineers Washington, D.C. Pilot Project". In January of 2018, Atticus completed the pilot project and submitted their report to Amtrak. Amtrak has incorporated the findings of the pilot project into initial and recurrent training programs for employees. The Crew Resource Management Modules for Train and Engine Service employees were revised to include recognition of potential distractors, methods to increase focus while performing train and engine service, and improving and maintaining situational awareness.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 1/25/2018
Response: We note that you are addressing this recommendation by contracting with an expert in the science of human attention to assess the potential causes of attention-related errors, with the hope of creating scenarios with operational challenges and unexpected circumstances that locomotive engineers may face in everyday operations. Please keep us informed as this project advances. Pending our receipt and evaluation of your results, Safety Recommendation R-16-37 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 has contracted with the Atticus Consulting Group LLC ('Atticus'), a leading expert in the science of human attention, to conduct an assessment of the potential causes of attention-related errors in its train operations and to initiate a pilot project to provide attention performance training to its Washington-based train engineers. This pilot project is referred to as the "Distraction, Affect and Attention Workplace Assessment (DA3)" and "Attention Performance Training for Amtrak Engineers Washington, DC, Pilot Project." Upon completion of the Pilot Project, Amtrak will perform an evaluation of the program with the intent of system-wide roll out of the training. The three goals of the pilot project are to: l. Identify the underlying causes of distraction and attention-related errors related to Amtrak's Washington, DC-based engineers; 2. Educate Amtrak senior leadership and operations management staff in the science of human attention and the potential for distraction in its Washington, DC, train operations; and 3. Train Amtrak's Washington, DC-based train engineers in the science of human attention and the core attention performance competencies necessary so that they will improve their abilities to manage unwanted internal cognitive and external operational and organizational distractions, effectively manage multiple concurrent tasks in prolonged, atypical situations, and effectively and consistently focus and sustain their attentional resources on current and prospective safety critical tasks related to train operations. The pilot project has five distinct phases. As of December 5, 2017, the project is in Phases 4 and 5. Phase 1: Initial Virtual Operations Review (100% Complete) Phase 2: On-site Operations Review (100% Complete) Phase 3: Distraction, Affect & Attention Workplace Assessment (DA3) (100% Complete) Phase 4: In-field Attention Performance Coaching under Live, Naturalistic Operations (20% Complete) Phase 5: Follow-up Distraction, Affect & Attention Workplace Assessment (DA3) (Currently in Progress) Positive Train Control Installation Status In December 2015, Amtrak activated PTC on track between New York and Washington, DC, completing installation on most Amtrak-owned infrastructure on the N01theast Corridor spine. The only exceptions are seven miles, all of which are located in or adjacent to terminal areas where trains move slower and automatic train control systems are in service. Of note, the following segments of the NEC are not owned by Amtrak: • Harold Interlocking east of New York Penn Station is owned by the Long Island Rail Road (LIRR); and • 56 miles between New Rochelle, New York, and New Haven, Connecticut, are owned by the states of New York and Connecticut with Metro-North Railroad (MNR) overseeing the installation of PTC. Amtrak has activated the PTC system on the 104-mile Harrisburg Line. Amtrak has also installed and is operating PTC along the 97 miles of track it owns in Michigan and Indiana, where PTC was introduced in 2002. Amtrak is working on installation of PTC on other lines, including the 60-mile Springfield line, the 105- mile Hudson line between Poughkeepsie and the Schenectady area (leased by Amtrak), and the 135-mile Dearborn-Kalamazoo segment of the Michigan line owned by Michigan, as well as the Chicago Union Station and New Orleans terminal areas. We remain committed to working diligently with our partners on the installation of PTC on these segments and throughout the Amtrak System by the mandated deadline of December 2018. In areas outside of Amtrak-owned track, we have been working closely with our host railroads to prepare for the commissioning of their PTC Systems. As of November 17, 2017, Amtrak installed 1-ETMS hardware on all of its off-corridor diesel locomotives and cab cars, except one NPCU which will be completed during overhaul. In addition, 44% of Amtrak's diesel locomotives 1-ETMS onboard system are commissioned. Amtrak plans to have all its locomotives and cab cars fully-commissioned and PTC ready before the December 31, 2018, deadline. I-ETMS (PTC) Summary Effective December 2017 Fleet: 21, Locomotive Types F59 Locomotives, Commissioned 6, Percent Complete 29% Fleet:18, Locomotive Types P32-8 Locomotives, Commissioned 4, Percent Complete 22% Fleet:18, Locomotive Types P32 Dual Mode Locomotives, Commissioned 2, Percent Complete 11% Fleet:8, Locomotive Types 8 Surfliner Cab Car, Commissioned 7, Percent Complete 88% Fleet:22, Locomotive Types NPCU (Formerly F40), Commissioned 2, Percent Complete 9% Fleet:197, Locomotive Types P42 Locomotives, Commissioned 102, Percent Complete 52% Fleet:13, Locomotive Types P40 Locomotives, Commissioned 9, Percent Complete 69% Fleet:4, Locomotive Types GENSET Locomotives, Commissioned 1, Percent Complete 25% To Date Total Completed 133 Total Fleet Quantity 301 Overall Total Percent Completed 44% I trust that the information contained within this letter is sufficient to address the open recommendations noted above. Our next progress update will be sent in June 2018. If additional information is required, please contact me.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 7/13/2017
Response: -From C.W. Moorman, President and Chief Executive Officer: Amtrak has contracted with the Atticus Consulting Group LLC, ('Atticus') a leading expert in the science of human attention, to conduct an assessment of the potential causes of attention-related errors in its train operations and to initiate a pilot project to provide attention performance training to its Washington based train engineers. This pilot project is referred to as the "Distraction, Affect and Attention Workplace Assessment (DA3)" and "Attention Performance Training for Amtrak Engineers Washington, DC, Pilot Project." Upon completion of the Pilot Project, Amtrak will perform an evaluation of the program with the intent of system-wide roll out of the training. The three goals of the pilot project are to: 1) Identify the underlying causes of distraction and attention-related errors related to Amtrak' s Washington, DC-based engineers, 2) Educate Amtrak senior leadership and operations management staff in the science of human attention and the potential for distraction in its Washington, DC train operations, 3) Train Amtrak's Washington, DC-based train engineers in the science of human attention and the core attention performance competencies necessary so that they will improve their abilities to manage unwanted internal cognitive and external operational and organizational distractions, effectively manage multiple concurrent tasks in prolonged, atypical situations, and effectively and consistently focus and sustain their attentional resources on current and prospective safety critical tasks related to train operations. The pilot project has five distinct phases. As of June 30, 2017, the project is progressing through phase [4], having completed phases [l , 2, and 3]. Phase 1: Initial Virtual Operations Review (100% Complete) Phase 2: On-site Operations Review (100% Complete) Phase 3: Distraction, Affect & Attention Workplace Assessment (DA3) (100% Complete). Phase 4: In-field Attention Performance Coaching under Live, Naturalistic Operations (0% Complete) Phase 5: Follow-up Distraction, Affect & Attention Workplace Assessment (DA3) (0% Complete) Amtrak will provide additional information relative to the pilot project in our next progress update. Positive Train Control Installation Status In December 2015, Amtrak activated PTC on track between New York and Washington, D.C., completing installation on most Amtrak-owned infrastructure on the Northeast Corridor spine. The only exceptions are seven miles, all of which are located in or adjacent to terminal areas where trains move slower and automatic train control systems are in service. Of note, the following segments of the NEC are not owned by Amtrak: • Harold Interlocking east of New York Penn Station is owned by the Long Island Rail Road (LIRR); • 56 miles between New Rochelle, NY and New Haven, CT are owned by the states of New York and Connecticut with Metro-North Railroad (MNR) overseeing the installation of PTC. Amtrak has activated the PTC system on the 104 mile Harrisburg Line. Amtrak has also installed and is operating PTC along the 97 miles of track it owns in Michigan and Indiana, where PTC was introduced in 2002. Amtrak is working on installation of PTC on other lines, including the 60 mile Springfield line (where a major double-tracking project funded by the state of Connecticut is underway), the I 05 mile Hudson line between Poughkeepsie and the Schenectady area (leased by Amtrak), and the 13 5 mile Dearborn Kalamazoo segment of the Michigan line owned by Michigan, as well as the Chicago Union Station and New Orleans terminal areas. We remain committed to the installation of PTC throughout the Amtrak System. In areas outside of Amtrak owned track, we have been working closely with our host railroads to prepare for the commissioning of our PTC Systems. As of June 30, 2017, Amtrak installed 1-ETMS hardware on all of its off-corridor diesel locomotives and cab cars, except two NPCUs which wi11 be completed during overhaul. Amtrak has 51 commissioned units with I-ETMS on board systems and plans to have all of its locomotives and cab cars fully PTC ready before the December 31 , 2018, deadline.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 10/31/2016
Response: -From C.W. Moorman, President and Chief Executive Officer: Amtrak has contracted with the Atticus Consulting Group LLC, ('Atticus') a leading expert in the science of human attention. Atticus will conduct an assessment of the potential causes of attention-related errors in its train operations and to initiate a pilot project to provide attention performance training to its Washington-based train engineers. This pilot project is referred to as the "Distraction, Affect and Attention Workplace Assessment (DA3)" and "Attention Performance Training for Amtrak Engineers Washington, DC, Pilot Project." Upon completion of the Pilot Project in December 2016, Amtrak will perform an evaluation of the program with the intent of system-wide roll out of the training. The three goals of the pilot project are to: 1. identify the underlying causes of distraction and attention-related errors related to Amtrak's Washington, DC-based engineers; 2. educate Amtrak senior leadership and operations management staff in the science of human attention and the potential for distraction in its Washington, DC, train operations; and 3. train Amtrak's Washington, DC-based train engineers in the science of human attention and the core attention performance competencies necessary so that they will improve their abilities to manage unwanted internal cognitive and external operational and organizational distractions, effectively manage multiple concurrent tasks in prolonged, atypical situations, and effectively and consistently focus and sustain their attentional resources on current and prospective safety critical tasks related to train operations. The pilot project has five distinct phases. As of September 30, 2016, the project is progressing through phase three, having completed phases one and two. • Phase 1: Initial Virtual Operations Review (100% Complete) • Phase 2: On-site Operations Review (1 00% Complete) • Phase 3: Distraction, Affect & Attention Workplace Assessment (DA3) (50% Complete) • Phase 4: In-field Attention Performance Coaching under Live, Naturalistic Operations (0% Complete) • Phase 5: Follow-up Distraction, Affect & Attention Workplace Assessment (DA3) (0% Complete) Amtrak will provide additional information relative to the pilot project in our next progress update. Positive Train Control Installation Status In December 2015, Amtrak activated PTC on track between New York and Washington, DC, completing installation on most Amtrak-owned infrastructure on the Northeast Corridor spine. The only exceptions are seven miles, all of which a:re located in or adjacent to terminal areas where trains move slower and automatic train control systems are in service. Of note, the following segments of the NEC are not owned by Amtrak: • Harold Interlocking east of New York Penn Station is owned by the Long Island Rail Road (LIRR); • 56 miles between New Rochelle, NY, and New Haven, CT, are owned by the states of New York and Connecticut with Metro-North Railroad (MNR) overseeing the installation of PTC. Amtrak has activated the PTC system on the I 04 mile Harrisburg Line. Amtrak has also installed and is operating PTC along the 97 miles of track it owns in Michigan and Indiana, where PTC was introduced in 2002. Amtrak is working on installation of PTC on other lines, including the 60-mile Springfield line (where a major double-tracking project funded by the state of Connecticut is underway), the I 05-mile Hudson line between Poughkeepsie and the Schenectady area (leased by Amtrak), and the 135-mile Dearborn Kalamazoo segment of the Michigan line owned by Michigan, as well as the Chicago Union Station and New Orleans terminal areas. We remain committed to the installation of PTC throughout the Amtrak System. In areas outside of Amtrak-owned track, we have been working closely with our host railroads to prepare for the commissioning of their PTC Systems. Ninety-seven percent (97%) of the off-corridor Amtrak Fleet is equipped with I-ETMS.