An Amtrak engineer who sped up at a curve — most likely because he was distracted by an emergency situation with another train — was determined as the probable cause of 2015's deadly Amtrak derailment in Philadelphia, the National Transportation Safety Board (NTSB) said Tuesday.
The Amtrak Northeast Regional Train 188, traveling from Washington D.C. to New York City derailed near Philadelphia on May13, 2015, killing eight people and injuring more than 200 passengers.
At a board meeting Tuesday, the NTSB said the probable cause of the derailment was the engineer's acceleration to 106 miles per hour at the end of a curve with a 50 mile per hour speed limit. The board blamed the acceleration to the engineer's loss of "situational awareness," likely because his attention was diverted when he heard another train was struck by rocks.
A contributing factor to the deadly accident was determined to be the lack of a Positive Train Control (PTC) system that is designed to prevent collisions, over-speed derailments, and other accidents.
In a statement, Amtrak said they took full responsibility for the derailment and would carefully review the NTSB recommendations.
"We have already completed the installation of Postivie Train Control on most of Amtrak's portion of the Northeast Corridor, and have also recently completed the installation of inward-facing video cameras in the fleet of ACS-64 locomotives in service on the Northeast Corridor," the statement said. "The goal is for us to fully understand what happened and how we can prevent a similar tragedy from occurring in the future."
According to the investigation's findings, a SEPTA commuter train had been struck with rocks minutes before the AMTRAK accident, shattering the windshield and getting glass in the SEPTA engineer's face. The Amtrak engineer, identified as Brandon Bostian, was "very concerned" about the SEPTA engineer who had requested medical attention. Bostian was also closely monitoring radio transmissions between the SEPTA engineer and a train dispatcher. Bostian lost his "situational awareness" because his attention was diverted to the SEPTA train incident, board members said, causing him to accelerate at the curve.
"While the loss of situational awareness can affect an operator's knowledge of where he currently is in time and space, it can also affect his ability to perform upcoming tasks," board member, Dr. Steve Jenner, said.
Bostian had told investigators he had no memory of the crash.
"He went in a matter of seconds from distraction to disaster," board member Robert Sumwalt said.
NTSB Chairman Christopher Hart said the board delved into what was the "most complicated and unpredictable part of the transportation system — the human being."
During the meeting, NTSB board members argued over whether the primary cause of the crash was the engineer's actions or the lack of PTC on the tracks. Some board members proposed to move PTC to the forefront of the probable cause findings as opposed to listing it as a contributing factor.
However, Hart said that PTC was a "backup" and a "safety net for human error." He said that even though "humans commit errors" he was concerned about removing the focus of the crash from the human performance and blaming lack of PTC as the probable cause. He added that the way to improve safety was to focus on human performance first.
"The engineer world is one of fallible human decisions and actions in an imperfect environment," Hart said.
Amtrak had not yet implemented the PTC system on the portion of the tracks where the derailment occurred. Congress had established a 2015 deadline to complete PTC which became a federal law after a 2008 collision between a Metrolink commuter train and a freight train left 25 people dead and 101 injured. After the 2015 derailment, Amtrak completed the PTC implementation on the Northeast corridor, except for 56 miles owned by New York and Connecticut which are targeted to be completed by an extended deadline of 2018.
The board provided other recommendations for improving safety, including calling for a study on installing seat belts in rail cars and methods to secure luggage that could turn deadly during a derailment. They also called for ways to improve coordination in transporting victims to hospitals.