Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation R-16-038
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 AMERICAN PUBLIC TRANSPORTATION ASSOCIATION AND THE ASSOCIATION OF AMERICAN RAILROADS: Develop criteria for initial and recurrent training for operating crewmembers that reinforce strategies for recognizing and effectively managing multiple concurrent tasks and prolonged, atypical situations to sustain their attention on current and upcoming train operations, and distribute those criteria to your members.
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: American Public Transportation Association (Open - Acceptable Response)
Association of American Railroads (Open - Unacceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: American Public Transportation Association
Date: 5/29/2019
Response: We note that, this year, your operating practices working group (OPWG) is planning to release revision 2 to APTA Standard RT-OP-S-013-03, “Standard for Training of Rail Operating Employees,” which provides requirements for developing and implementing rail transit system operations training programs for rail-operating employees, including initial qualification and requalification. Please send us a copy of revision 2 of the standard when it is released, or describe the sections of the revision that address the recommended criteria for initial and recurrent training. Pending our review of that information, Safety Recommendation R-16-38 is classified OPEN--ACCEPTABLE RESPONSE.

From: American Public Transportation Association
To: NTSB
Date: 1/28/2019
Response: -From Paul P. Skoutelas, President and Chief Executive Officer: APTA, through its Operating Practices Working Group (OPWG), has developed and published a Standard for Training of Rail Operating Employees in 2003 and subsequently updated it in 2014 as Revision 1. This standard is titled: “APTA RT-OP-S-013-03 Standard for Training of Rail Operating Employees.” The document is currently going through its 5-year review cycle and will be republished as Revision 2 in early 2019. We will include reference to the NTSB Recommendation in the final document. This standard provides requirements for the development and implementation of rail transit system operations training programs for rail operating employees. Elements include training program development, testing phases, qualification, requalification, performance tracking, training program revision and training documentation. This standard also outlines the basic elements required for a comprehensive rail operating employee training and retraining program. The purpose of a comprehensive training program is to ensure there is consistent and complete training of all appropriate rail operating employees covered by this standard. Such a program requires each employee to have a base of knowledge that is consistent across his or her particular job. The program also ensures that the rail transit system provides initial qualification and requalification. These recommended practices are developed by industry members, and therefore constitute consensus among the rail transit agencies. Once these recommended practices (if accepted) are approved by the Rail Transit CEOs and the Bus Transit CEOs Committees, member agencies are made aware of their publication. APTA believes it has met the intent of the NTSB Recommendation R 16-38, and accordingly requests that the recommendation be classified as “closed.”

From: NTSB
To: American Public Transportation Association
Date: 10/16/2018
Response: In the 2 years since we issued this recommendation, we have not received any information on your actions to satisfy it, and it is currently classified OPEN--AWAIT RESPONSE.

From: NTSB
To: American Public Transportation Association
Date: 6/9/2016
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. We are providing the following information to urge the American Public Transportation Association to take action on the safety recommendation being issued in this letter. On May 17, 2016, we adopted our 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-14-74to the Federal Railroad Administration; reclassified Safety Recommendations R-15-28, R-15-29, and R-15-30to Amtrak; closed Safety Recommendation R-13-23to the Federal Railroad Administration; and issued 11 new safety recommendations, including five to the Federal Railroad Administration; one to Amtrak; 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 safety recommendation to the Association of American Railroads and the American Public Transportation Association: R-16-38 Develop criteria for initial and recurrent training for operating crewmembers that reinforce strategies for recognizing and effectively managing multiple concurrent tasks and prolonged, atypical situations to sustain their attention on current and upcoming train operations, and distribute those criteria to your members. Chairman HART, Vice Chairman DINH-ZARR, and Members SUMWALT and WEENER concurred in this recommendation. The NTSB is vitally interested in this recommendation because it is designed to prevent accidents and save lives. We would appreciate receiving a response from you within 90days detailing the actions you have taken or intend to take to implement it. When replying, please refer to the safety recommendation by number. We encourage you to submit your response electronically to correspondence@ntsb.gov. If it exceeds 10megabytes, including attachments, please e-mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response.

From: NTSB
To: Association of American Railroads
Date: 6/21/2017
Response: Your letter indicates that railroads currently use training methods that you believe address the intent of this recommendation. You state that railroads conduct on-the-job employee training that complies with the requirements of Title 49 Code of Federal Regulations Parts 240 and 242. You also write that Class 1 railroads and some short line railroads use simulators to present atypical situations, and you highlight that railroads are required to use job briefings at the beginning of each new shift, as conditions change, and at the beginning of field training exercises. Although these actions are laudable, we do not believe they meet the intent of this recommendation. The current training activities described in your letter do not address developing and sharing criteria for initial and recurrent training to be used to train operating crewmembers to recognize and effectively manage multiple concurrent tasks over a prolonged period so their attention is focused on operating the train during atypical situations. We encourage you to reconsider your current position on this issue. Until you develop and share with your members criteria for initial and recurrent training, as described in Safety Recommendation R 16 38, it is classified OPEN--UNACCEPTABLE RESPONSE.

From: Association of American Railroads
To: NTSB
Date: 10/28/2016
Response: -From Edward R. Hamberger, President and CEO: Upon receipt of this recommendation, AAR surveyed its member railroads to determine the practices that are in place and ascertain how current employee training addresses the importance of managing multiple tasks and maintaining operational safety. AAR learned that all railroads have applicable rules and training that emphasizes the unique nature of the railroad work environment during training of both locomotive engineers and conductors. Railroads address handling concurrent tasks in myriad ways. • On-the-job training at employees' assigned territories that complies with requirements for periodic and initial training in 49 CFR §§ 240 and 242. • All Class 1 railroads and some smaller railroads use simulators to present strategies for handling concurrent tasks and atypical situations. • A short line railroad, for example, practices the concept of "Cab Situational Awareness" during critical times such as approaching the limits of authority or a speed restriction. Crews are trained to limit cab communication to immediate responsibilities for safe train operation. Class 1 railroads have established similar practices known by such names as Sterile Cab, Cab Red Zone, and Clean Cab Communications. • Job briefings are held at the beginning of training in the field to confirm requirements, address potential hazards, and to highlight responses in the event conditions change. In conclusion, the rail industry does provide training to operating crewmembers that addresses managing concurrent tasks. Therefore, we believe that Safety Recommendation R-16-38 should be given the status of "Closed-Reconsidered." If you or your staff have any questions regarding railroad training of operational personnel, please contact me or Mr. Michael Martino for additional information. Thank you.

From: Association of American Railroads
To: NTSB
Date: 10/28/2016
Response: Edward R. Hamberger, President and CEO: At the conclusion of its investigation of the May 12, 2015, derailment of Amtrak Train 188, the NTSB issued the following recommendation to the American Public Transportation Administration ("APTA") and the Association of American Railroads ("AAR"): Develop criteria for initial and recurrent training for operating crewmembers that reinforce strategies for recognizing and effectively managing multiple concurrent tasks and prolonged, atypical situations to sustain their attention on current and upcoming train operations, and distribute those criteria to your members. (R-16-38) Upon receipt of this recommendation, AAR surveyed its member railroads to determine the practices that are in place and ascertain how current employee training addresses the importance of managing multiple tasks and maintaining operational safety. AAR learned that all railroads have applicable rules and training that emphasizes the unique nature of the railroad work environment during training of both locomotive engineers and conductors. Railroads address handling concurrent tasks in myriad ways. • On-the-job training at employees' assigned territories that complies with requirements for periodic and initial training in 49 CFR §§ 240 and 242. • All Class 1 railroads and some smaller railroads use simulators to present strategies for handling concurrent tasks and atypical situations. • A short line railroad, for example, practices the concept of "Cab Situational Awareness" during critical times such as approaching the limits of authority or a speed restriction. Crews are trained to limit cab communication to immediate responsibilities for safe train operation. Class 1 railroads have established similar practices known by such names as Sterile Cab, Cab Red Zone, and Clean Cab Communications . • Job briefings are held at the beginning of training in the field to confirm requirements, address potential hazards, and to highlight responses in the event conditions change. In conclusion, the rail industry does provide training to operating crewmembers that addresses managing concurrent tasks. Therefore, we believe that Safety Recommendation R-16-38 should be given the status of "Closed-Reconsidered." If you or your staff have any questions regarding railroad training of operational personnel, please contact me or Mr. Michael Martino for additional information. Thank you.