Amtrak Train 188 Tragic Accident – What is the Complete Story?

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#1
The Amtrak Train 188 derailment on May 12, 2015 at Frankford Junction Curve in Northeast Philadelphia was a terrible tragedy. Eight passengers died and scores were injured, many seriously. The National Transportation Safety Board (NTSB) conducted their usual detailed investigation and determined the accident’s probable cause. Train 188, operating northbound from Washington to New York City, entered the 50 mph curve at 106 mph, a very unsafe speed, because of what is called “situational awareness.” The train’s engineer Brandon Bostian apparently lost track of where he was on the route, and believed that he was beyond this unusually sharp curve when he was not.

The investigation established that Engineer Bostian had a clean disciplinary record, was not impaired by drugs or alcohol, and he was not using a cell phone or any other personal electronic device. Shortly before the accident, a SEPTA train on an adjacent track stopped because of a thrown rock shattering that train’s windshield. There was much radio chatter about the SEPTA incident as Train 188 approached the fateful curve, and this may have distracted Bostian. All the available evidence points to the conclusion that the locomotive engineer failed to properly control his train’s speed simply because of losing track of where he was in the nighttime darkness – human failure at the worst possible time. The NTSB’s assessment and commentary are “spot on” based on the known facts.

The NTSB reported that Positive Train Control (PTC), mandated by Congress in 2008, had not yet been implemented at the time of the accident on that portion of the Northeast Corridor. The NTSB also found that “the accident could have been avoided if positive train control or another control system had been in place to enforce the permanent speed restriction of 50 mph at the Franklin (sic) Junction Curve.”

As detailed as the NTSB’s accident report is, its findings are somewhat incomplete and even misleading. That is because a fully capable train control system was in place at the time of the accident. The necessary equipment has been on the Northeast Corridor passenger locomotives, including Train 188, for at least 50 years, and this train control system has also been part of the Northeast Corridor wayside signaling between New York City and Washington, including at Frankford Junction, for even longer than that.

As mentioned in the NTSB report, this long existing train control system is called Automatic Train Control (ATC), and consists of cab signaling with speed enforcement and limiting. Cab signaling on a locomotive inductively receives signal system information transmitted by the wayside signaling through the running rails, and provides a display in the locomotive cab of the safe speed (sometimes a signal aspect denoting speed requirements) based on the real time conditions ahead of the train. The ATC speed enforcement feature stops the train if the engineer does not comply with the cab signal speed. At Frankford Junction, this longstanding ATC equipment has provided protection that forces trains to slowdown when approaching preceding trains and stop signals. This existing safety system also forces trains to slowdown for lower speed turnouts when switching from track to track.

Prior to the accident and as reported by the NTSB, this existing ATC equipment even forced slowdowns for some Northeast Corridor curves, including this very Frankford Junction Curve in the southbound direction. However, Train 188 was operating northbound, and the ATC system was not used to display or enforce a reduced speed for the Frankford Junction Curve in the northbound direction. Yes, the necessary equipment had been in place on the locomotives and in the wayside signaling for over 50 years, something the NTSB did not fully explain. As Train 188 approached and entered the 50 mph curve, the cab signal displayed and permitted the locomotive’s maximum speed of 125 mph, even though lower cab signal speeds were available. To its credit, the NTSB did conclude that ATC cab signaling protection for the Frankford Junction Curve “would have prevented the accident.” But why wasn’t this existing ATC equipment used to force northbound trains down to a safe speed before reaching the curve?

Although no mention was found in the NTSB report about speed signs approaching the accident curve, Dennis Pierce, president of the Brotherhood of Locomotive Engineers and Trainmen, said to a congressional committee that “the simple use of speed signs in the approach to the curve, as a reminder, may have prevented this accident.” The Federal Railroad Administration (FRA) Emergency Order 31 issued after the accident directed Amtrak to “enhance speed restriction signage.” It is hard to fathom why a railroad line with speeds up to 150 mph wouldn’t have signs approaching low speed curves, and why the NTSB’s report didn’t address this issue.

Excessive speeds on railway curves have caused many tragic accidents over the years. One of the early and more serious accidents of this type occurred November 1, 1918 on the Brooklyn Rapid Transit’s Brighton Beach Line in New York City. Known as the Malbone Street Wreck, somewhere between 93 and 103 people died and many others were seriously injured.

Two notable train wrecks occurred in the United States during the 1950s because of excessive speed on curves – one on what is now the Northeast Corridor at Jenkins Curve in Bridgeport Connecticut, and the other at Redondo Junction in Southern California. For these two excessive speed accidents, a total of 31 died and 175 were injured. Such excessive speed accidents are not peculiar only to the United States, but have occurred around the world with some frequency. For one 50 mph curve in Morpeth, England, there have been three serious excessive speed derailments in modern times – in 1969, 1984 and 1994. For the three accidents at this one curve there were a total of 6 fatalities and 57 injured.

These types of excessive speed accidents virtually always involve human failure and associated factors such as loss of situational awareness, distraction, forgetfulness, drowsiness, falling asleep, and on occasion impairment.

The first accident that is particularly germane to the Frankford Junction accident occurred 8:23 AM December 12, 1990 on Amtrak’s Northeast Corridor at Back Bay in Boston. Amtrak Train 66 operating from Washington to Boston approached the 30 mph speed restriction and curve entering Back Bay Station at excessive speed. The resulting derailment and crash into a commuter train on an adjacent track injured 453 people, not counting 175 additional claims of injury that were made after the fact. One of many interesting factors about the Back Bay accident was that the engineer’s 4:30 AM report time in New Haven, Connecticut for the assignment made it likely that he had to arise somewhere around 3:00 AM or earlier – a difficult wakeup time for most human beings.

The NTSB reported that the Back Bay accident’s probable cause was human failure with several significant contributing factors, one of which was “Amtrak’s failure to have advanced warning devices for a speed reduction for the curve entering Back Bay Station.” This wording didn’t make clear that both the Back Bay locomotive and wayside signaling were already equipped with the ATC cab signaling and speed enforcement system, and that this preexisting safety system was not used to force trains to slowdown for the curve.

The Back Bay accident on the Northeast Corridor was a loud wakeup call. America’s most prestigious and highest speed rail line had modern ATC cab signaling with speed enforcement and limiting capability, but this safety system was rarely used to force trains to slowdown to safe speeds for curves. In the aftermath of the Back Bay accident, Amtrak after conferring with the FRA reconfigured the existing ATC system and equipment to force speed reductions approaching the Back Bay Curve. Amtrak also rearranged the existing ATC cab signal equipment at some other locations to limit train speeds approaching curves, including the Frankford Junction Curve in the southbound direction, but not in the northbound direction.

Several foreign curve excessive speed accidents occurred in recent years and were widely reported in the American news media. Two of the more pertinent accidents occurred in Japan and Spain. The Amagasaki rail crash in April 2005 took 107 lives and injured 562, and Spain’s Santiago de Compostela derailment and rollover in July 2013 was caught on dramatic video and resulted in 79 dead and 140 injured. These and other similar excessive speed accidents were caused by human failure and the lack of safety systems. As these accidents illustrate, the number of deaths and injuries resulting from excessive speed accidents can reach catastrophic levels.

Then on December 1, 2013, a southbound Metro North Railroad commuter train derailed after entering Spuyten Duyvil Curve in New York City at excessive speed. This accident resulted in 4 deaths and 61 injured. The engineer was believed to have fallen asleep while at the controls of the fast moving train, and he was later diagnosed to have severe obstructive sleep apnea. The NTSB found that a contributory factor to the accident “was the absence of a positive train control system.” However, the Metro North trains and wayside signaling have had ATC cab signaling with speed enforcement and limiting for several decades, which system was and is fully capable of preventing curve excessive speed accidents. It wasn’t absent; it just wasn’t used for that purpose.

In response to the Spuyten Duyvil accident, the FRA issued Emergency Order 29 requiring the Metro North Railroad to use its existing ATC train control system to provide for safety wherever the authorized speed dropped by more than 20 mph. For example, if the track approaching a 50 mph curve is authorized for 80 mph, the speed reduction at the curve would be 30 mph, and the existing ATC system had to be used to ensure safe speeds were enforced. Metro North modified the signaling approaching the Spuyten Duyvil Curve and approaching all other speed restrictions on its entire rail network that were covered by the FRA emergency directive. Thanks to the ATC system, the Spuyten Duyvil accident should never happen again on the Metro North Railroad.

The wreck of Amtrak Train 188 in Northeast Philadelphia occurred less than two years after the Metro North accident and the FRA’s issuance of Emergency Order 29. The permitted speed approaching Frankford Junction Curve for Train 188 was 80 mph and the curve was timetabled for 50 mph – a 30 mph speed drop. Two questions were never raised or answered by the NTSB. Why didn’t the FRA make Emergency Order 29 applicable to Amtrak and all rail lines already equipped with an ATC train control system? Was it because the FRA believed the Amtrak locomotive engineers are less fallible than those of Metro North, and those in Spain and Japan?

There was much commentary reported in the news media about Bostian’s 106 mph speed being reckless. Of course, that speed was wrong and unsafe at that location. However, 106 mph is not an unusual speed for Amtrak trains when operating on the Northeast Corridor. For Bostian’s Train 188 run from Washington to New York, major stretches had authorized speeds of 110 to 125 mph. In fact, as the NTSB reported, the authorized speed immediately beyond the Frankford Junction area was 110 mph. The speed of 106 mph was quite a normal speed for Train 188, but it was a wrong and dangerous speed before being past the Frankford Junction Curve. Sadly, as the NTSB has made clear, situational awareness has been a significant factor in many transportation fatal accidents. That is one important reason why there are safety systems to protect against human error.

The NTSB railroad accident reports have not looked at the bigger picture and possible systemic problems and failures, especially with respect to those responsible for railroad signal systems here in North America. For instance, neither the NTSB nor the FRA ever mentioned how passenger railroad safety systems in the United States compare with those on our own domestic rail transit systems, especially with respect to limiting train speeds when necessary for safety – such as approaching curves.

It just happens that many of our modern heavy rail transit systems in the United States have had their signal systems enforce all speed restrictions, including all curves, beginning more than 40 years ago. This level of safety has been provided on the PATCO Speedline between Philadelphia and New Jersey since 1969, on San Francisco Bay Area’s BART rail network since 1972, on WMATA in our nation’s capital since 1976, and on Atlanta’s MARTA since 1979. The maximum speeds on these transit systems are relatively low and range from 65 to 80 mph. Since Amtrak trains on the Northeast Corridor operate up to 125, 135 and 150 mph depending on location and train type, it seems very incongruous that the Northeast Corridor curve speeds weren’t all speed limited long ago.

While the NTSB report is correct in its technical detail and findings, it does not provide a top down and broad assessment about how such an unnecessary and tragic accident could occur on Amtrak’s Northeast Corridor in this 21st Century. The safety technology not only existed, but was in place at Frankford Junction for more than 50 years. No new equipment was required. The public deserves to know why, after the Metro North accident and many other speed related accidents here in the United States and around the world, FRA Emergency Order 29 was not made applicable to Amtrak. And the public should be told why the FRA allowed the Spuyten Duyvil curve to not be protected by the existing signal system equipment until after that unnecessary fatal accident.

Focusing on Engineer Brandon Bostian and his performance was a necessary part of the accident investigation. However, his human failing is dwarfed by the failure of the FRA and the railroads to enforce safe speeds before these accidents occurred, by using long existing equipment for very little cost. The complete story of the Amtrak Train 188 accident deserves to be told.

Comments are requested and will be appreciated.
 
#3
Thanks for the comment. Actually there were no technical failures at Frankford Junction.. All the existing technology worked fine. The cab signaling has been slowing trains for many years when there is a train ahead, a signal at stop, switching from track to track, and even for some curves. The ATC is great safety technology. Even though ATC was in place for 50 years, it just wasn't used at Frankford Junction to slow Bostian's train for the curve.

The failures that led to the accident were all by human beings, including the FRA and Amtrak management.
 

Ed Sand

General Idiot
#4
Excellent analysis that sadly was passed over in the rush to PTC. Amtrak simply wasn't willing to invest the work it would have taken to make ATC more comprehensive, when all their efforts were focused on PTC.

Panacea Train Control
 
#5
The question why the ATC wasn’t used a long time ago and before the accident is well above my pay grade. So I cannot respond. The NTSB should have reported that the equipment to slow passenger trains for the curve was installed for at least 50 years. No new equipment was required. The NTSB report hides that Amtrak and the FRA did nothing to limit train speeds for this unusually sharp bend until after the accident, even though the ATC was very capable to limit trains to safe speeds.
 



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