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Safety Recommendation Details

Safety Recommendation R-16-039
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 PHILADELPHIA POLICE DEPARTMENT AND PHILADELPHIA OFFICE OF EMERGENCY MANAGEMENT: Collaborate and develop a plan that effectively integrates rapid police transport of patients into the emergency medical response plans for large mass casualty incidents, including a means of coordinating hospital destinations regardless of the method of transport.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
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: 8/7/2018
Addressee(s) and Addressee Status: Commonwealth of Pennsylvania, City of Philadelphia, Office of Emergency Management (Closed - Acceptable Action)
Commonwealth of Pennsylvania, City of Philadelphia, Police Department (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Commonwealth of Pennsylvania, City of Philadelphia, Police Department
Date: 8/7/2018
Response: We note that when this derailment occurred, you were in the process of revising the city’s mass casualty plan (MCP). Based on a series of exercises conducted before and after the derailment and your postaccident analysis of the city’s response, you finalized your MCP in June 2016. It now integrates the use of police transport for victims of a mass casualty event, to be coordinated by the emergency medical services branch director or patient transportation group supervisor, both of which are positions staffed by a senior member of the Philadelphia Fire Department. In the MCP, police vehicles are used to transport patients who have been triaged with a green tag, indicating they have the least serious injuries. The June 2016 version of Philadelphia’s MCP satisfies Safety Recommendation R-16-39, which is classified CLOSED--ACCEPTABLE ACTION for both the Philadelphia Police Department and the Philadelphia OEM.

From: NTSB
To: Commonwealth of Pennsylvania, City of Philadelphia, Police Department
Date: 9/15/2016
Response: The National Transportation Safety Board (NTSB) has reviewed the National Highway Traffic Safety Administration (NHTSA) “Request for Information: Nationally Uniform 911 Data Systems,” published at 81 Federal Register 27904 on June 30, 2016. The proposed nationally uniform 911 data system would contain uniform data elements for all computer-aided dispatch (CAD) systems. These self-defining data would facilitate the collection, analysis, and sharing of all CAD data received, collected, processed, and transmitted during 911 calls, including administrative and cost data. These data, in turn, would be made available to all 911 public safety answering points (PSAP) and 911 authorities at the state and local levels. NHTSA poses 15 questions, of which three are applicable to the NTSB. Question 1 addresses significant changes in 911 data systems over the last 10 years, question 2 addresses the usefulness of the data that would be created by implementing a nationally uniform 911 system, and question 3 focuses on the most critical issues facing the current use and interconnection of PSAP CAD systems. Critical Issues in Current Use and Future Development of PSAP CAD Systems (question 3) Additional research is needed to understand the issues facing the current use and future development of PSAP CAD systems. Uniform data can facilitate that research, as NHTSA describes in its Request for Information. The NTSB supports the proposed development of a uniform 911 data system. A mass casualty incident (MCI) is one of the most critical scenarios for PSAP operations because it requires a wide range of resources. Well-established response plans and efficient communication are critical for proper execution of the response. The derailment of Amtrak passenger train 188 in Philadelphia, Pennsylvania, on May 12, 2015, was an MCI in which 186 people were brought to local hospitals?all but 24 of whom were transported by police vehicles rather than ambulances. Our investigation found that this method can be reasonable, but it requires a high level of integration of the emergency response system. We concluded that poor coordination of the transfer of victims resulted in the overuse of some hospitals. The NTSB issued the following safety recommendation to the Philadelphia Police Department and the Philadelphia Office of Emergency Management: Collaborate and develop a plan that effectively integrates rapid police transport of patients into the emergency medical response plans for large mass casualty incidents, including a means of coordinating hospital destinations regardless of the method of transport. (R-16-39) This recently issued recommendation is currently classified “Open?Await Response.” The Amtrak derailment in Philadelphia is a good example of how uniform data systems could be a valuable tool for improving and integrating communication during MCIs, and ultimately improving PSAP functions. The development of PSAP CAD systems should also follow existing guidance for ensuring complete and functional backup systems, including providing adequate training of personnel. The May 23, 2013, collapse of the Interstate 5 Skagit River Bridge following a strike by an oversize combination vehicle in Mount Vernon, Washington, resulted in the disruption of the 911 communication system. Backup systems were in place and worked reasonably well; however, deficiencies were found in the training for, and implementation of, the US Department of Homeland Security Government Emergency Telecommunications Service system.

From: Commonwealth of Pennsylvania, City of Philadelphia, Police Department
To: NTSB
Date: 9/6/2016
Response: -From Michael DiBerardinis, Managing Director, City of Philadelphia: When the Amtrak 188 derailment occurred, the City of Philadelphia was in the process of revising the City's Mass Casualty Plan (MCP) and was in the middle of an exercise series which was designed to test portions of the MCP. The exercise series commenced with a workshop on May 11, 2015, the day prior to the derailment, a Table-Top Exercise on June 9, 2015, and a FullScale Exercise on July 29, 2015. The lessons observed at these three exercises and the response to Amtrak 188 have informed the refinement and finalization of the City's Mass Casualty Plan. Specifically, in regards to recommendation R-16-39, the MCP does integrate the use of police transport for victims of a mass casualty incident. However, the plan calls for this integration to be coordinated through the EMS Branch Director or Patient Transportation Group Supervisor, both positions which will be staffed by a senior member of the Philadelphia Fire Department. This coordination is optimal because it ensures that patients are transported in the most appropriate vehicle based on their injuries and transported to a facility that can provide the best care. Failing to coordinate this transportation could result in a need for subsequent transports between healthcare facilities due to overcrowding or the need for special zed medical service. On scene coordination will help to minimize these instances thus ensuring appropriate care is provided as quickly as possible. Furthermore, on scene coordination aides in patient tracking which is essential in connecting family members with those injured. The MCP also states that police transport will be used for patients who receive green triage tags -an indication of minor injury. This is a recommendation, but certainly one that will be driven by several factors including the size of the incident (number of injured and extent of injuries) and other incidents occurring simultaneously within the city. Both of these circumstances could modify the availability of resources and require on-scene adaptation and quick-thinking that is required of first responders on a daily basis. Regarding recommendation R-16-40, we fully agree and, at minimum, will leverage the triennial Airport Emergency Drill (EPEX) to test the City's mass casualty program. We will continue to conduct trainings and exercises independent of EPEX, as well. In addition to responding to the recommendations, we would like to address a couple of points from the Railroad Accident Report adopted May 17, 2016. 1. The report is slightly inconsistent about the recommended role of police transports in a mass casualty incident. It speaks to the need for and importance of coordination, but suggests that this coordination would create delays and diminish the purpose of utilizing police transports, ideal for swift transport. We believe, and will plan, train, and exercise, in a manner that best integrates police, but does so in coordination with the Philadelphia Fire Department. By doing so, we can best utilize the first responder and hospital system as a whole. 2. Page 34 of the Report states that the two communications systems used within the city (Police Radio and Fire Communications Center) do not routinely communicate with each other. These centers coordinate and communicate with each other on a daily basis, and even more so during major emergencies and events. 3. Page 35 of the Report states that OEM has not finalized its after-action report of the incident. By the date of adoption of the Railroad Report, the City's after-action report was finalized. This is dated information from interviews conducted earlier in the investigation process. 4. Finally, page 33 of the Report questions why Temple Hospital received 43 patients and Penn Presbyterian received zero "although the distance was similar." The difference in distance between the crash site and the hospitals is nearly 7 miles. While seemingly insignificant, 7 miles in an urban, highly congested environment is considerable. o 2021 Wheatsheaf Lane to Temple Hospital (3.4 miles) o 2021 Wheatsheaf Lane to Penn Presbyterian (10.3 miles) We have enclosed two documents which further outline our response to ass casualty incidents and the continued work we will do to further improve our capabilities. We respectfully request that these documents not be shared or disseminated without prior approval by the City of Philadelphia. City of Philadelphia: Mass Casualty Plan (June 2016) City of Philadelphia: Amtrak 188 Derailment After Action Review (December 2015) Thank you again for the thorough investigation and review of the Amtrak 188 derailment. Mayor Kenney and I are committed to continuing to improve our public safety programs and appreciate the work of the NTSB in helping us do this.

From: NTSB
To: Commonwealth of Pennsylvania, City of Philadelphia, Office of Emergency Management
Date: 8/7/2018
Response: We note that when this derailment occurred, you were in the process of revising the city’s mass casualty plan (MCP). Based on a series of exercises conducted before and after the derailment and your postaccident analysis of the city’s response, you finalized your MCP in June 2016. It now integrates the use of police transport for victims of a mass casualty event, to be coordinated by the emergency medical services branch director or patient transportation group supervisor, both of which are positions staffed by a senior member of the Philadelphia Fire Department. In the MCP, police vehicles are used to transport patients who have been triaged with a green tag, indicating they have the least serious injuries. The June 2016 version of Philadelphia’s MCP satisfies Safety Recommendation R-16-39, which is classified CLOSED--ACCEPTABLE ACTION for both the Philadelphia Police Department and the Philadelphia OEM.

From: NTSB
To: Commonwealth of Pennsylvania, City of Philadelphia, Office of Emergency Management
Date: 9/15/2016
Response: The National Transportation Safety Board (NTSB) has reviewed the National Highway Traffic Safety Administration (NHTSA) “Request for Information: Nationally Uniform 911 Data Systems,” published at 81 Federal Register 27904 on June 30, 2016. The proposed nationally uniform 911 data system would contain uniform data elements for all computer-aided dispatch (CAD) systems. These self-defining data would facilitate the collection, analysis, and sharing of all CAD data received, collected, processed, and transmitted during 911 calls, including administrative and cost data. These data, in turn, would be made available to all 911 public safety answering points (PSAP) and 911 authorities at the state and local levels. NHTSA poses 15 questions, of which three are applicable to the NTSB. Question 1 addresses significant changes in 911 data systems over the last 10 years, question 2 addresses the usefulness of the data that would be created by implementing a nationally uniform 911 system, and question 3 focuses on the most critical issues facing the current use and interconnection of PSAP CAD systems. Critical Issues in Current Use and Future Development of PSAP CAD Systems (question 3) Additional research is needed to understand the issues facing the current use and future development of PSAP CAD systems. Uniform data can facilitate that research, as NHTSA describes in its Request for Information. The NTSB supports the proposed development of a uniform 911 data system. A mass casualty incident (MCI) is one of the most critical scenarios for PSAP operations because it requires a wide range of resources. Well-established response plans and efficient communication are critical for proper execution of the response. The derailment of Amtrak passenger train 188 in Philadelphia, Pennsylvania, on May 12, 2015, was an MCI in which 186 people were brought to local hospitals?all but 24 of whom were transported by police vehicles rather than ambulances. Our investigation found that this method can be reasonable, but it requires a high level of integration of the emergency response system. We concluded that poor coordination of the transfer of victims resulted in the overuse of some hospitals. The NTSB issued the following safety recommendation to the Philadelphia Police Department and the Philadelphia Office of Emergency Management: Collaborate and develop a plan that effectively integrates rapid police transport of patients into the emergency medical response plans for large mass casualty incidents, including a means of coordinating hospital destinations regardless of the method of transport. (R-16-39) This recently issued recommendation is currently classified “Open?Await Response.” The Amtrak derailment in Philadelphia is a good example of how uniform data systems could be a valuable tool for improving and integrating communication during MCIs, and ultimately improving PSAP functions. The development of PSAP CAD systems should also follow existing guidance for ensuring complete and functional backup systems, including providing adequate training of personnel. The May 23, 2013, collapse of the Interstate 5 Skagit River Bridge following a strike by an oversize combination vehicle in Mount Vernon, Washington, resulted in the disruption of the 911 communication system. Backup systems were in place and worked reasonably well; however, deficiencies were found in the training for, and implementation of, the US Department of Homeland Security Government Emergency Telecommunications Service system.

From: Commonwealth of Pennsylvania, City of Philadelphia, Office of Emergency Management
To: NTSB
Date: 9/6/2016
Response: -From Michael DiBerardinis, Managing Director, City of Philadelphia: When the Amtrak 188 derailment occurred, the City of Philadelphia was in the process of revising the City's Mass Casualty Plan (MCP) and was in the middle of an exercise series which was designed to test portions of the MCP. The exercise series commenced with a workshop on May 11, 2015, the day prior to the derailment, a Table-Top Exercise on June 9, 2015, and a FullScale Exercise on July 29, 2015. The lessons observed at these three exercises and the response to Amtrak 188 have informed the refinement and finalization of the City's Mass Casualty Plan. Specifically, in regards to recommendation R-16-39, the MCP does integrate the use of police transport for victims of a mass casualty incident. However, the plan calls for this integration to be coordinated through the EMS Branch Director or Patient Transportation Group Supervisor, both positions which will be staffed by a senior member of the Philadelphia Fire Department. This coordination is optimal because it ensures that patients are transported in the most appropriate vehicle based on their injuries and transported to a facility that can provide the best care. Failing to coordinate this transportation could result in a need for subsequent transports between healthcare facilities due to overcrowding or the need for special zed medical service. On scene coordination will help to minimize these instances thus ensuring appropriate care is provided as quickly as possible. Furthermore, on scene coordination aides in patient tracking which is essential in connecting family members with those injured. The MCP also states that police transport will be used for patients who receive green triage tags -an indication of minor injury. This is a recommendation, but certainly one that will be driven by several factors including the size of the incident (number of injured and extent of injuries) and other incidents occurring simultaneously within the city. Both of these circumstances could modify the availability of resources and require on-scene adaptation and quick-thinking that is required of first responders on a daily basis. Regarding recommendation R-16-40, we fully agree and, at minimum, will leverage the triennial Airport Emergency Drill (EPEX) to test the City's mass casualty program. We will continue to conduct trainings and exercises independent of EPEX, as well. In addition to responding to the recommendations, we would like to address a couple of points from the Railroad Accident Report adopted May 17, 2016. 1. The report is slightly inconsistent about the recommended role of police transports in a mass casualty incident. It speaks to the need for and importance of coordination, but suggests that this coordination would create delays and diminish the purpose of utilizing police transports, ideal for swift transport. We believe, and will plan, train, and exercise, in a manner that best integrates police, but does so in coordination with the Philadelphia Fire Department. By doing so, we can best utilize the first responder and hospital system as a whole. 2. Page 34 of the Report states that the two communications systems used within the city (Police Radio and Fire Communications Center) do not routinely communicate with each other. These centers coordinate and communicate with each other on a daily basis, and even more so during major emergencies and events. 3. Page 35 of the Report states that OEM has not finalized its after-action report of the incident. By the date of adoption of the Railroad Report, the City's after-action report was finalized. This is dated information from interviews conducted earlier in the investigation process. 4. Finally, page 33 of the Report questions why Temple Hospital received 43 patients and Penn Presbyterian received zero "although the distance was similar." The difference in distance between the crash site and the hospitals is nearly 7 miles. While seemingly insignificant, 7 miles in an urban, highly congested environment is considerable. o 2021 Wheatsheaf Lane to Temple Hospital (3.4 miles) o 2021 Wheatsheaf Lane to Penn Presbyterian (10.3 miles) We have enclosed two documents which further outline our response to ass casualty incidents and the continued work we will do to further improve our capabilities. We respectfully request that these documents not be shared or disseminated without prior approval by the City of Philadelphia. City of Philadelphia: Mass Casualty Plan (June 2016) City of Philadelphia: Amtrak 188 Derailment After Action Review (December 2015) Thank you again for the thorough investigation and review of the Amtrak 188 derailment. Mayor Kenney and I are committed to continuing to improve our public safety programs and appreciate the work of the NTSB in helping us do this.