Engineer's Distraction, Lack of Positive Train Control Technology Cited in Amtrak Crash

"It's widely understood that every person, no matter how conscientious and skilled, is fallible, which is why technology was developed to backstop human vulnerabilities," said NTSB Chairman Christopher A. Hart. "Had positive train control been in place on that stretch of track, this entirely preventable tragedy would not have happened."

The National Transportation Safety Board concluded May 17 that the derailment of an Amtrak train in May 2015 along the Northeast Corridor in Philadelphia resulted from "a loss of situational awareness" by the train's engineer when he was distracted by learning of an emergency involving another train. Eight passengers died when the Amtrak train en route from Washington, D.C., to New York City derailed as it negotiated a curve at 106 mph, more than twice the authorized speed of 50 mph.

"It's widely understood that every person, no matter how conscientious and skilled, is fallible, which is why technology was developed to backstop human vulnerabilities," said NTSB Chairman Christopher A. Hart. "Had positive train control been in place on that stretch of track, this entirely preventable tragedy would not have happened."

NTSB determined that the engineer, who was cooperative when interviewed after the crash, was not impaired by any substance and was not using his cell phone at the time, nor was there evidence that he was fatigued or suffering from any pre-existing medical condition. "In interviews the Amtrak engineer indicated that he was concerned for the well-being of a commuter train engineer, whose locomotive had just been struck by an object, spraying that engineer with glass from the windshield. The radio communications about that emergency, in which the Amtrak engineer participated and listened, lasted six minutes and, preceded the derailment by less than one minute," according to NTSB. "Investigators determined the Amtrak engineer became distracted by the emergency involving the commuter train and lost situational awareness as to where his train was located in relation to the curve with the 50 mph speed restriction. The acceleration past 100 mph before entering the curve where the derailment occurred was consistent with a belief that his train had already passed the curve into an area of relatively straight track where the authorized speed was 110 mph."

NTSB also called attention to the fact that some of the train's windows failed to remain intact throughout the accident sequence. If the windows had not failed, some passengers who were thrown from the train and died probably would have remained inside the train and survived, according to the board's findings.

Positive train control implementation for passenger trains had been required to be completed by the end of 2015, but Congress extended the deadline until 2018 and delayed enforcement of the regulation for two years more. "Unless positive train control 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," Hart said.

The board issued 11 safety recommendations, including five to the Federal Railroad Administration; others were directed to Amtrak, 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 Philadelphia, the National Association of State EMS Officials, the National Volunteer Fire Council, the National Emergency Management Association, the National Association of Emergency Medical Service Physicians, the National Association of Chiefs of Police, and the International Association of Fire Chiefs.

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