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Speeches

Board Meeting : Philadelphia Amtrak 188 Derailment Accident, Closing Statement
Christopher A. Hart
NTSB Conference Center, Washington, DC
5/17/2016

​In closing, I would like to recognize the hard work of the NTSB staff in producing this report. In particular, I would like to recognize Karen Bury, who wrote this report. Karen will be retiring at the end of June after 30 years of federal service – 24 of them with the NTSB. During that time, Karen has played a number of significant roles at this agency, and has truly been an asset in the pursuit of the improvement of transportation safety. We wish her all the best.

I also thank my fellow Board Members for their very thoughtful participation in our deliberations today and I especially like to thank Member Robert Sumwalt for being a board member on scene.

I stated at the outset of this meeting that this derailment would never have occurred had PTC been active on the Frankford Junction Curve. The dozens of lives lost in PTC-preventable tragedies since 2008 are mute but powerful testament to the importance of finishing the job.

Today’s recommendations can make railroads safer by helping crewmembers identify train positions and upcoming routes in areas where PTC will not be available to provide that information.

We searched for any involvement of drugs, alcohol, or fatigue, and found none. We looked at the weather, the locomotive, and the track, and determined that this was a good train on good track, with an engineer who was fit for duty, not fatigued, not impaired by drugs or alcohol, and not distracted by a personal electronic device.

But we have long known that even in the absence of such factors, human beings are fallible, making a technological backstop, such as PTC, a necessity.

And we asked Amtrak to improve training based on how human cognition copes with concurrent tasks. Our deep look into the human cognitive mechanisms that underlie situational awareness points toward the importance of understanding prospective memory as a way to reduce error in human decision making. This area may hold many insights and solutions to human performance in safety-critical operations, such as operating trains.

We also learned more about what happens in the crash of a passenger railcar, pointing out the need for immediate work to improve survivability in passenger trains, such as restraint systems and the securing of items that might act as projectiles in a crash. Improving the securement of passenger windows also is needed immediately. And we asked, as we always do, what lessons we might have missed. While inward-facing image recorders are required by the FAST act, they were not available in this accident, depriving investigators of valuable insight into what happened in the critical moments surrounding the derailment.

Inward-facing cameras will tell investigators more about what happened in the train cab in the moments before any future accidents, and can help railroads gather data that can be used for both operational and safety improvements.

There has been resistance to the installation of such cameras in the past. Other measures – such as PTC – have also faced implementation hurdles. Installation of image recorders on commuter and passenger railroads should be completed in time for nationwide PTC implementation – if progress on both initiatives proceeds according to the timelines that have been established by Congress.

Unless PTC is implemented soon, I’m very concerned that we’re going to be back in this room again, hearing investigators detail how technology that we have recommended for more than 45 years could have prevented yet another fatal rail accident.

As I mentioned in my opening statement, the real deadline for PTC implementation is not 2018, but the next PTC-preventable accident. Because we do not know when that might occur, it is time to make every day count.

We stand adjourned.

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