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Safety Recommendation Details

Safety Recommendation R-16-040
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: Once the plan specified in Safety Recommendation R-16-39is developed, practice the plan periodically, including at least one full-scale drill every 3 years, to ensure that it functions as intended.
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, at a minimum, you will conduct an airport emergency drill every 3 years to test the city’s MCP, and you plan to conduct training events and exercises independent of this drill, as well. We must stress that it is very important that MCP drills are not limited to airport-based scenarios. As your MCP points out, mass casualty events can occur in a variety of settings and for a variety of reasons; therefore, it is vital that Philadelphia’s first responders and others involved in responding to a mass casualty event can practice using your MCP outside an airport-based scenario, as well. However, your plan to conduct at least one full-scale drill every 3 years satisfies Safety Recommendation R 16-40, which is classified CLOSED--ACCEPTABLE ACTION for both the Philadelphia Police Department and the Philadelphia OEM.

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, Police Department
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 Philadelphia Police Department to take action on the safety recommendations being issued in this letter. On May 17, 2016,we adopted our report concerning the May 12, 2015,accidentin 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 five to the Federal Railroad Administration; one to Amtrak; 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; one to the Association of American Railroads and the American Public Transportation Association; and the following two safety recommendations to the Philadelphia Fire Department, Philadelphia Office of Emergency Management, and the Philadelphia Police Department: R-16-39 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-16-40 Once the plan specified in Safety Recommendation R-16-39is developed, practice the plan periodically, including at least one full-scale drill every 3 years, to ensure that it functions as intended. Chairman HART, Vice Chairman DINH-ZARR, and Members SUMWALT and WEENER concurred in these recommendations. The NTSB is vitally interested in these recommendations because they are 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 them. When replying, please refer to the safety recommendations 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: Commonwealth of Pennsylvania, City of Philadelphia, Office of Emergency Management
Date: 8/7/2018
Response: We note that, at a minimum, you will conduct an airport emergency drill every 3 years to test the city’s MCP, and you plan to conduct training events and exercises independent of this drill, as well. We must stress that it is very important that MCP drills are not limited to airport-based scenarios. As your MCP points out, mass casualty events can occur in a variety of settings and for a variety of reasons; therefore, it is vital that Philadelphia’s first responders and others involved in responding to a mass casualty event can practice using your MCP outside an airport-based scenario, as well. However, your plan to conduct at least one full-scale drill every 3 years satisfies Safety Recommendation R 16-40, which is classified CLOSED--ACCEPTABLE ACTION for both the Philadelphia Police Department and the Philadelphia OEM.

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.

From: NTSB
To: Commonwealth of Pennsylvania, City of Philadelphia, Office of Emergency Management
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 Philadelphia Office of Emergency Management to take action on the safety recommendations being issued in this letter. On May 17, 2016,we adopted our report concerning the May 12, 2015,accidentin 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; and closed Safety Recommendation R-13-23 to the Federal Railroad Administration; and issued 11 new safety recommendations, including five to the Federal Railroad Administration; one to Amtrak; 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; one to the Association of American Railroads and the American Public Transportation Association; and the following two safety recommendations to the Philadelphia Police Department, the Philadelphia Fire Department, and the Philadelphia Office of Emergency Management: R-16-39 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-16-40 Once the plan specified in Safety Recommendation R-16-39is developed, practice the plan periodically, including at least one full-scale drill every 3 years, to ensure that it functions as intended. Chairman HART, Vice Chairman DINH-ZARR, and Members SUMWALT and WEENER concurred in these recommendations. The NTSB is vitally interested in these recommendations because they are 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 them. When replying, please refer to the safety recommendations 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.