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Safety Recommendation Details

Safety Recommendation R-15-030
Details
Synopsis: About 9:21 p.m. on May 12, 2015, National Railroad Passenger Corporation (Amtrak) passenger train 188 derailed at milepost 81.62 near Frankfort Junction in Philadelphia, Pennsylvania. The tracks in the area of the derailment have a 4-degree curve with a permanent speed restriction of 50 mph. Event recorder data indicated the train was traveling 106 mph when the engineer made an emergency brake application; soon afterward, the train derailed at the curve. There were 250 passengers and 8 Amtrak employees on board. Eight passengers died, and more than 200 passengers were treated for injuries.
Recommendation: TO THE NATIONAL RAILROAD PASSENGER CORPORATION (AMTRAK): Regularly review and use in-cab audio and image recordings in conjunction with other performance data to verify crew member actions are in accordance with rules and procedures that are essential to safety.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
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: 7/8/2015
Date Closed: 1/25/2018
Addressee(s) and Addressee Status: Amtrak (National Railroad Passenger Corporation) (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 9/12/2018
Response: We previously acknowledged that you developed a policy for using data obtained from inward and outward-facing audio and image recording. We have reviewed your efficiency-testing program and determined that the information obtained from the in-cab audio and image recordings, in conjunction with other performance testing, satisfies the intent of this recommendation. Accordingly, Safety Recommendation R-15-30 is classified CLOSED--ACCEPTABLE ACTION.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 7/6/2018
Response: -From Kenneth J. Hylander, Executive Vice President and Chief Safety Officer: Amtrak has developed a policy for the use of data obtained by inward- and outward-facing audio and image recorders; this policy governs access and use of the data to verify crewmember compliance with safety rules and procedures. In January of 2018, NTSB updated that status of this recommendation, determining Amtrak's response as "Closed- Acceptable Action" Amtrak continues to review locomotive operating data from the audio and image recording devices as part of our safety program. Over three hundred reviews have occurred in the past two years.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 1/25/2018
Response: We are encouraged that you have developed a policy for using data obtained from inward and outward-facing audio and image recording. We have reviewed your efficiency-testing program and determined that the information obtained from the in-cab audio and image recordings, in conjunction with other performance testing, satisfies the intent of this recommendation. Accordingly, Safety Recommendation R-15-30 is classified CLOSED--ACCEPTABLE ACTION.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 12/28/2017
Response: -From Richard H. Anderson, President and Chief Executive Officer: Amtrak has developed a policy for the use of data obtained by inward- and outward-facing audio and image recorders. This policy governs access and use of the data to verify crewmember compliance with safety rules and procedures. Additionally, Amtrak has developed a specific test classification, TEST 140, as part of the Efficiency Testing program. This test reviews compliance with rules that govern prohibited behaviors and attention to duty while occupying the cab of a locomotive or on-track equipment equipped with inward-facing audio and image recordings. Supervisors qualified as designated examiners have received training in the retrieval and review of data from the recording system. Amtrak has shared the detailed TEST criteria in prior submissions to the NTSB. The criteria remain unchanged. Attached is a summary report of the Efficiency TESTS performed using inward-facing cameras since the requirement was added to the testing program. 231 Tests have been recorded to date, with 5 failures noted.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 7/13/2017
Response: -From C.W. Moorman, President and Chief Executive Officer: Amtrak has developed a policy for the use of data obtained by inward- and outward-facing audio and image recorders; this policy governs access and use of the data to verify crewmember compliance with safety rules and procedures. Additionally, Amtrak has developed a specific test classification, TEST 140, as part of the Efficiency Testing program. This test reviews compliance with rules that govern prohibited behaviors and attention to duty while occupying the cab of a locomotive or on-track equipment equipped with inward facing audio and image recordings. Supervisors qualified as designated examiners have received training in the retrieval and review of data from the recording system. Amtrak has shared the detailed TEST criteria in prior submissions to NTSB. The criteria remains unchanged. Enclosed is a summary report of the Efficiency TESTS performed using inward facing cameras since the requirement was added to the testing program. There have been a total of 92 Tests recorded to date, with 2 non-compliances noted with regard to PPE.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 10/31/2016
Response: -From C.W. Moorman, President and Chief Executive Officer: Amtrak has developed a policy for the use of data obtained by inward- and outward-facing audio and image recorders. This policy governs access and use of the data to verify crewmember compliance with safety rules and procedures. Enclosed is the policy documentation. Additionally, Amtrak has developed a specific test classification, TEST 140, as part of the Efficiency Testing program. This test reviews compliance with rules that govern prohibited behaviors and attention to duty while occupying the cab of a locomotive or on-track equipment equipped with inward-facing audio and image recordings. Supervisors qualified as designated examiners have received training in the retrieval and review of data from the recording system. Enclosed is the TEST 140 documentation.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 6/9/2016
Response: Safety Recommendations R-15-28 through R-15-30 were reclassified in NTSB Railroad Accident Report RAR-16-02, concerning the May 12, 2015 accident in which Amtrak passenger train 188 derailed in Philadelphia, Pennsylvania. The engineer’s inability to report what happened in the moments before the accident presented a challenge to investigators. Inward-facing audio and image recorders in the cab would have provided important information in this case—and many others—to assist investigators in understanding what happened. Such cameras are installed on some trains and have assisted the NTSB in recent investigations. As a result, on July 8, 2015, the NTSB issued the following recommendations to Amtrak: R-15-28 Install, in all controlling locomotive cabs and cab car operating compartments, crash- and fire-protected inward-and outward-facing audio and image recorders capable of providing recordings to verify that train crew actions are in accordance with rules and procedures that are essential to safety as well as train operating conditions. The devices should have a minimum 12-hour continuous recording capability with recordings that are easily accessible for review, with appropriate limitations on public release, for the investigation of accidents or for use by management in carrying out efficiency testing and systemwide performance monitoring programs R-15-29 Semi-annually, issue a public report detailing Amtrak’s progress in installing crash- and fire-protected inward- and outward-facing audio and image recorders. The report should include the number of locomotives and cab car operating compartments that have been equipped with the recorders, as well as the number of locomotives and cab car operating compartments in Amtrak’s fleet that still lack those devices R-15-30 Regularly review and use in-cab audio and image recordings in conjunction with other performance data to verify crewmember actions are in accordance with rules and procedures that are essential to safety. In a letter dated March 10, 2016, Amtrak reported that it had installed inward-facing video cameras meeting the specifications in the recommendation on its current fleet of 57 ACS-64 locomotives and that it continues to install them throughout the fleet. Amtrak stated it was planning to install crash-hardened units incorporating event recorders on its fleet and would release another installation progress report in October 2016. Amtrak also stated it had developed a policy for the use of data obtained by inward- and outward-facing audio and image recorders. On the basis of this response, recommendations R-15-28 through -30 are classified OPEN—ACCEPTABLE RESPONSE.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 5/25/2016
Response: We are encouraged that you have developed a policy for the use of data obtained from the use of inward- and outward-facing audio and image recording We would like to review Amtrak’s efficiency-testing program to determine whether the information obtained from the in-cab audio and image recordings, in conjunction with other performance testing, is being effectively used to ensure safe rail operations. For example, we would like to know who reviews the recorded information, how often it is reviewed, and whether you share information gleaned from the review with the operating employee. Accordingly, please provide the policy and testing program for our review. In the meantime, Safety Recommendation R-15-30 is classified OPEN—ACCEPTABLE RESPONSE.

From: Amtrak (National Railroad Passenger Corporation)
To: NTSB
Date: 3/10/2016
Response: -From Joseph H. Boardman, President and Chief Executive Officer: Amtrak has developed a policy for the use of data obtained by inward- and outward-facing audio and image recorders. This policy governs access and use of the data to verify crew member compliance with safety rules and procedures. Positive Train Control Installation Status In December 2015, Amtrak activated PTC on track between New York and Washington, DC, completing installation on most Amtrak-owned infrastructure on the Northeast Corridor (NEC) spine. The only exceptions are seven (7) miles, all of which are located in or adjacent to terminal areas where trains move slower and automatic train control systems are in service. Of note, the following segments of the NEC are not owned by Amtrak: • Harold Interlocking east of New York Penn Station is owned by the Long Island Rail Road (LIRR); • 56 miles between New Rochelle, NY, and New Haven, CT, are owned by the states of New York and Connecticut with Metro-North Railroad (MNR) overseeing the installation of PTC. Amtrak is testing the PTC system on the 1 04-mile Harrisburg Line with phased activation of line segments through March 2016. The segment from Park to Harrisburg, approximately sixty (60) miles in length, was activated on March 5, 2016. The remaining segments will be activated by the end of March. Amtrak has also installed and is operating PTC along the ninety-seven (97) miles of track it owns in Michigan and Indiana, where PTC was introduced in 2002. Amtrak is working on installation of PTC on other lines, including the 60-mile Springfield line (where a major double-tracking project funded by the state of Connecticut is underway), the 1 05-mile Hudson line between Poughkeepsie and the Schenectady area (leased by Amtrak), and the 135-mile Dearborn Kalamazoo segment of the Michigan line owned by Michigan, as well as the Chicago Union Station and New Orleans terminal areas. We remain committed to the installation of PTC throughout the Amtrak System.