# 2015 Philadelphia train derailment NTSB report

NTSB/RAR-16/02 PB2016-103218 Notation 8714B Adopted May 17 2016
Railroad Accident Report
Derailment of Amtrak Passenger Train 188 Philadelphia, Pennsylvania May 12, 2015
* National Transportation Safety Board
490 L‘Enfant Plaza, SW. Washington. DC. 20594
​National Transportation Safety Board. 2016. Derailment of Amtrak Passenger Train 188 Philadelphia, Pennsylvania, May 12, 2015. Railroad Accident Report NTSB/RAR-16/02. Washington, DC.
Abstract: At 9:21 p.m. eastern daylight time on May 12, 2015, eastbound Amtrak passenger train 188 derailed in Philadelphia, Pennsylvania, with 245 passengers and 8 Amtrak employees on board. The train had just entered the Frankford Junction curve—where the speed is restricted to 50 mph—at 106 mph. As the train entered the curve, the locomotive engineer applied the emergency brakes. Seconds later, the train derailed. Eight passengers died, and 185 others were transported to area hospitals.
This report addresses the following safety issues: crewmember situational awareness and management of multiple tasks; positive train control; passenger railcar window systems and occupant protection; and transportation of the injured after mass casualty incidents.
As a result of the investigation of this accident, the National Transportation Safety Board makes recommendations to Amtrak, the Federal Railroad Administration, the American Public Transportation Association, the Association of American Railroads, the Philadelphia Police Department, the Philadelphia Fire Department, the Philadelphia Office of Emergency Management, the mayor of the city of Philadelphia, the National Association of State EMS (Emergency Medical Services) 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.
The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation, "accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties. .. and are not conducted for the purpose of determining the rights or liabilities of any person." 49 CFR § 831.4. Assignment of fault or legal liability is not relevant to the NTSB's statutory mission to improve transportation safety by investigating accidents and incidents and issuing safety recommendations. In addition, statutory language prohibits the admission into evidence or use of any part of an NTSB report related to an accident in a civil action for damages resulting from a matter mentioned in the report. 49 USC § 1154(b).
For more detailed background information on this report, visit http://www.ntsb.gov/investigations/dms.html and search for NTSB accident ID DCA15MR010. Recent publications are available in their entirety on the Internet at http://www.ntsb.gov. Other information about available publications also may be obtained from the website or by contacting: National Transportation Safety Board, Records Management Division, CIO-40, 490 L'Enfant Plaza, SW, Washington, DC 20594, (800) 877-6799 or (202) 314-6551

### ContentsContents

* Figures and Tables................................................................................................................................................................................................................................................................................................................................................................................................iii
* Abbreviations and Acronyms................................................................................................................................................................................................................................................................................................................................................................................................iv
* Executive Summary................................................................................................................................................................................................................................................................................................................................................................................................vi
* 1.Investigation and Analysis ................................................................................................................................................................................................................................................................................................................................................................................................1
* 1.1Synopsis................................................................................................................................................................................................................................................................................................................................................................................................1
* 1.2Accident Scenario................................................................................................................................................................................................................................................................................................................................................................................................2
* 1.3Amtrak................................................................................................................................................................................................................................................................................................................................................................................................5
* 1.4Analysis of the Engineer’s Actions................................................................................................................................................................................................................................................................................................................................................................................................6
* 1.4.1Loss of Situational Awareness................................................................................................................................................................................................................................................................................................................................................................................................9
* 1.4.2Need for Improved Crew Training and Advanced Technologies................................................................................................................................................................................................................................................................................................................................................................................................11
* 1.5Signal and Train Control Information................................................................................................................................................................................................................................................................................................................................................................................................13
* 1.5.1Positive Train Control................................................................................................................................................................................................................................................................................................................................................................................................14
* 1.5.2Two-Person Crews................................................................................................................................................................................................................................................................................................................................................................................................17
* 1.6Train Information................................................................................................................................................................................................................................................................................................................................................................................................20
* 1.6.1Postaccident Testing................................................................................................................................................................................................................................................................................................................................................................................................21
* 1.7Personnel Information................................................................................................................................................................................................................................................................................................................................................................................................21
* 1.8Survival Factors................................................................................................................................................................................................................................................................................................................................................................................................22
* 1.8.1The Derailment Sequence................................................................................................................................................................................................................................................................................................................................................................................................22
* 1.8.2Damage to Passenger Car Windows and Injuries................................................................................................................................................................................................................................................................................................................................................................................................23
* 1.8.3Occupant Protection in Derailment Scenarios................................................................................................................................................................................................................................................................................................................................................................................................26
* 1.9Emergency Medical Response................................................................................................................................................................................................................................................................................................................................................................................................28
* 1.9.1Incident Management................................................................................................................................................................................................................................................................................................................................................................................................28
* 1.9.2Transportation of the Injured................................................................................................................................................................................................................................................................................................................................................................................................29
* 1.9.3Amtrak’s Passenger Accountability System................................................................................................................................................................................................................................................................................................................................................................................................36
* 1.10Factors Not Contributing to This Accident................................................................................................................................................................................................................................................................................................................................................................................................37
* 2Postaccident Actions................................................................................................................................................................................................................................................................................................................................................................................................38
* 2.1NTSB Recommendations................................................................................................................................................................................................................................................................................................................................................................................................38
* 2.2FRA Emergency Order................................................................................................................................................................................................................................................................................................................................................................................................40
* 2.3Amtrak................................................................................................................................................................................................................................................................................................................................................................................................41
* 3Conclusions................................................................................................................................................................................................................................................................................................................................................................................................42
* 3.1Findings................................................................................................................................................................................................................................................................................................................................................................................................42
* 3.2Probable Cause................................................................................................................................................................................................................................................................................................................................................................................................44
* 4Recommendations................................................................................................................................................................................................................................................................................................................................................................................................45
* 4.1New Recommendations................................................................................................................................................................................................................................................................................................................................................................................................45
* 4.2Previously Issued Recommendations Arising from this Accident................................................................................................................................................................................................................................................................................................................................................................................................46
* 4.3Previously Issued Recommendation Reiterated in this Report................................................................................................................................................................................................................................................................................................................................................................................................47
* 4.4Previously-Issued Recommendations Classified in this Report................................................................................................................................................................................................................................................................................................................................................................................................48
* Board Member Statements................................................................................................................................................................................................................................................................................................................................................................................................49
* Appendix A: Investigation................................................................................................................................................................................................................................................................................................................................................................................................57
* Appendix B: Transcript of Radio Transmissions................................................................................................................................................................................................................................................................................................................................................................................................58
* Appendix C: Sample of Recent NTSB Accident Investigations with Two-Person Crews Involving Noncompliance with Signals or Instructions................................................................................................................................................................................................................................................................................................................................................................................................60

### Figures and TablesFigures and Tables

* Figure 1. Accident scene.................................................................................................................................................................................................................................................................................................................................................................................................1
* Figure 2. Train 188 intended route................................................................................................................................................................................................................................................................................................................................................................................................3
* Figure 3. Train 188's route through Philadelphia.................................................................................................................................................................................................................................................................................................................................................................................................4
* Figure 4. Amtrak routes throughout the United States.................................................................................................................................................................................................................................................................................................................................................................................................5
* Figure 5. PTC (ACSES) was installed on the Northeast Corridor in 2000.................................................................................................................................................................................................................................................................................................................................................................................................15
* Figure 6. Accident site showing derailed cars, catenary structures locations.................................................................................................................................................................................................................................................................................................................................................................................................23
* Figure 7. Damaged catenary supports (left); example of undamaged catenary supports (right).................................................................................................................................................................................................................................................................................................................................................................................................23
* Figure 8. Photograph showing damaged right side of car 3.................................................................................................................................................................................................................................................................................................................................................................................................24
* Figure 9. Close-up of damaged windows on right side of car 4.................................................................................................................................................................................................................................................................................................................................................................................................24
* Figure 10. Map of hospitals near derailment and accident patients treated as of 1:30 a.m. the night of the accident.................................................................................................................................................................................................................................................................................................................................................................................................30
* Figure 11. Map of hospitals near derailment and more even distribution of accident patients.................................................................................................................................................................................................................................................................................................................................................................................................30
* Table 1. Injuries.................................................................................................................................................................................................................................................................................................................................................................................................2
* Table 2. Cab Signal Indications................................................................................................................................................................................................................................................................................................................................................................................................13
* Table 3. Amtrak Train 188.................................................................................................................................................................................................................................................................................................................................................................................................20

### Abbreviations and AcronymsAbbreviations and Acronyms

| AAR | Association of American Railroads |
| ACSES | Advanced Civil Speed Enforcement System |
| AIS | Abbreviated Injury Scale |
| Amtrak | National Railroad Passenger Corporation |
| ATC | automatic train control |
| BLET | Brotherhood of Locomotive Engineers and Trainmen |
| CFR | Code of Federal Regulations |
| Conrail | Consolidated Rail Corporation |
| CT | computed tomography |
| CRM | crew resource management |
| DOT | US Department of Transportation |
| EMS | Emergency Medical Services |
| eTicketing | electronic ticketing |
| FAST | Fixing America’s Surface Transportation |
| FRA | Federal Railroad Administration |
| GAO | Government Accountability Office |
| MARC | Maryland Area Regional Commuter |
| MCI | mass casualty incident |
| Metra | Northeast Illinois Regional Commuter Railroad |
| MP | milepost |
| NORAC | Northeast Operating Rules Advisory Committee (Operating Rulebook) |
| NPRM | notice of proposed rulemaking |
| NTSB | National Transportation Safety Board ​ |
| OEM | Office of Emergency Management (Philadelphia) |
| PFD | Philadelphia Fire Department |
| PPD | Philadelphia Police Department |
| PTC | positive train control |
| SEPTA | Southeastern Pennsylvania Transportation Authority |
| USC | United States Code |