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Safety Recommendation Details

Safety Recommendation R-16-042
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 INTERNATIONAL ASSOCIATION OF CHIEFS OF POLICE, INTERNATIONAL ASSOCIATION OF FIRE CHIEFS, NATIONAL ASSOCIATION OF STATE EMS OFFICIALS, NATIONAL EMERGENCY MANAGEMENT ASSOCIATION, NATIONAL VOLUNTEER FIRE COUNCIL: Educate your members regarding the details of this accident, including the lessons learned from the emergency medical response, and the potential utility of integrating police transport of victims into mass casualty incident response plans.
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: International Association of Fire Chiefs (Closed - Acceptable Action)
National Association of State EMS Officials (Open - Acceptable Response)
National Emergency Management Association (Closed - Acceptable Action)
National Volunteer Fire Council (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: International Association of Fire Chiefs
Date: 6/22/2017
Response: In his e-mail, Mr. Goldstein included a link to a November 18, 2016, article you published in On Scene, an IAFC member publication, and that you have posted on your website. The article, titled “EMS: Police Transport of MCI Victims,” discussed the May 12, 2015, Amtrak train 188 derailment and alternatives to emergency medical services that may improve the survival of patients involved in a mass causality incident. Publication of the article satisfies Safety Recommendation R-16-42, which is classified CLOSED--ACCEPTABLE ACTION.

From: International Association of Fire Chiefs
To: NTSB
Date: 11/21/2016
Response: -From Jim Goldstein, Government Relations, International Association of Fire Chiefs: In response to NTSB correspondence to Mark Light, CEO and Executive Director of the International Association of Fire Chiefs (IAFC), please see the attached article published in “ON Scene” which is sent electronically to our 11,000 plus members. The IAFC believes that this satisfies the NTSB recommendation. Please let me know if you need anything else regarding this safety recommendation.

From: NTSB
To: National Association of State EMS Officials
Date: 8/28/2018
Response: On June 28, 2016, Mr. Paul R. Patrick, then President of NASEMSO, said that you would be discussing our investigation findings and this recommendation during your fall meeting in September 2016. On August 24, 2016, we replied that, although this was an opportunity to reach many of your members, we were concerned that your entire membership might not attend this meeting. We suggested that you send a newsletter to your members and post a notice on your website regarding our recommendation, then provide us with a record of your actions for our review. Pending those actions, Safety Recommendation R-16-42 was classified OPEN--ACCEPTABLE RESPONSE We have not received any further information in the 2 years since your previous letter.

From: NTSB
To: National Association of State EMS Officials
Date: 8/24/2016
Response: We note that you will be discussing our investigation findings and the subsequent recommendation to integrate police transport into casualty response plans during your fall meeting in September 2016. Although this is an opportunity to reach many of your members, it is possible that your entire membership may not attend this meeting. We suggest that you send a newsletter to all your members and post a notice on your website regarding this recommendation. Once you have taken these steps and verified that you have shared the recommendation with all your members, please provide us with a record of your actions for our review. Until we receive further updates on your actions to address it, Safety Recommendation R-16-042 is classified OPEN--ACCEPTABLE RESPONSE.

From: National Association of State EMS Officials
To: NTSB
Date: 6/28/2016
Response: -From Paul R. Patrick, President, National Association of State EMS Officials: This correspondence is in response to NTSB Recommendation R-16-42 issued by the National Transportation Safety Board (NTSB) on June 9, 2016. Thank you for including the National Association of State EMS Officials (NASEMSO) in the safety recommendation from the NTSB regarding the Amtrak derailment; which occurred in Philadelphia, Pennsylvania on May 12, 2015. NASEMSO is concerned with these findings as they relate to Emergency Medical Services (EMS) and will be sharing them with our membership. NASEMSO’s Domestic Preparedness Committee will be discussing the safety board’s recommendations at our annual meeting in New Mexico on September 19-23, 2016. Based on the Domestic Preparedness Committee’s review of the recommendations concerning the Amtrak derailment, to include lessons learned from the EMS response, the committee will provide recommendations to the NASEMSO Executive Board for their approval. Subsequently, I will forward our action steps to you for consideration. Again, thank you for giving NASEMSO the opportunity to review the NTSB recommendations and to share them with national EMS leaders. If you have any questions or additional information you would like to share with our membership, please email them to Joe Schmider, Chair of the Domestic Preparedness Committee.

From: NTSB
To: National Emergency Management Association
Date: 8/10/2018
Response: We note that the day after we issued this recommendation, you e-mailed all state emergency management directors about it and informed them that the related accident report was available. Issuing this notice satisfies Safety Recommendation R-16-42, which is classified CLOSED--ACCEPTABLE ACTION.

From: NTSB
To: National Volunteer Fire Council
Date: 8/10/2018
Response: We note that, shortly after we issued this recommendation, you sent a notice to your members providing a link to our Amtrak 188 accident report and pointing out that the report contained findings and recommendations of interest to first responders. Issuing this notice satisfies Safety Recommendation R-16-42, which is classified CLOSED--ACCEPTABLE ACTION.

From: National Volunteer Fire Council
To: NTSB
Date: 6/25/2018
Response: -From Dave Finger, Chief of Legislative and Regulatory Affairs, National Volunteer Fire Council: We notified our membership about the existence of both of these reports through articles in our electronic newsletter (https://www.nvfc.org/ntsb-releases-final-report-on-philadelphia-trainderailment/) (https://www.nvfc.org/ntsb-issues-findings-on-paulsboro-train-derailment-that-led-tohazardous-materials-release/). We also discussed both incidents at NVFC board meetings. The feedback from the discussion of the Philadelphia incident was that it was interesting to note that using police for mass casualty transport worked as well as it did, but we weren’t sure how applicable the lessons learned there would be for our membership generally. For one thing, in Philadelphia there were a lot of law enforcement resources on the ground before there were EMS resources on the ground. In most rural areas, which is where our members operate, that is not generally going to be the case. Fire/EMS is typically going to get there first, and there are usually going to be more fire/EMS personnel on the scene than law enforcement. The other issue that came up was differences in transport time in the Philadelphia case compared with in a rural area. It is one thing to throw a patient in the back seat for a 5-minute ride to a hospital. It is quite another if the nearest hospital is much farther away. In that scenario you would probably want to do more on-scene medical intervention and triage before you start transporting people, particularly since some patients may need to be airlifted to trauma centers, which are not common in rural areas. We have not directly addressed the directive in R-14-27 to “incorporate into ongoing training curricula lessons learned concerning the need to promptly use adequate data collection and analysis tools and to develop and implement community protective measures for mitigating the threats of hazardous materials releases” mainly because we don’t provide operational training and therefore have no vehicle through which to accomplish this. We are about to launch a new resource called FD PREPP through a partnership with PHMSA that addresses much of what is in the directive, although it focuses specifically on responses to pipeline incidents. Let me know if you have any questions.