David Schanoes’ personal analysis of the Amtrak train No. 188 derailment at Frankford Junction curve on the Northeast Corridor last year elicited a response from National Transportation Safety Board Director Robert J. Hall, P.E. We publish it in full:
I would like the opportunity to address some of the comments made by David Schanoes in the Railway Age article, “The short, the long, the skinny, and the fat” regarding the National Transportation Safety Board (NTSB) investigation and findings regarding the derailment of Amtrak train 188 in Philadelphia, Pennsylvania, on May 12, 2015.
The article states, “NTSB is not going to tell you anything 12 months from the incident that you won’t already know within a day or two, if you do your work, and if you don’t abdicate your responsibility.”
A comprehensive accident investigation cannot be conducted hastily. It is an exhaustive process that involves developing and supporting the most plausible factors contributing to the accident. Also as challenging is the need to rule out factors that we know can lead to an accident. Consider the effort needed to eliminate the following variables that the NTSB has previously identified as contributing to major transportation accidents: operator fatigue (due to irregular and unpredictable crew scheduling, obstructive sleep apnea, circadian disruption); medical conditions (including seizures, diabetes, and color blindness); use of prescription and nonprescription medications; illicit drugs; alcohol; inadequate training and testing of operating and signal rules; poor signal conspicuity; train dispatcher errors; and distraction due to text messaging and cell phone calls. It takes time and great effort to analyze these variables to assess if they played a role in an accident. From the NTSB’s perspective, any conclusion about the cause of the Amtrak accident that was formulated just days after the accident would be purely speculative, incomplete, and lacking a thorough analysis of relevant information.
The article states, “Call it loss of situational awareness, if you want. I like calling it what it is—failure to properly control the speed of the train, no matter what.”
This statement is a simple explanation of what happened. Indeed, event recorder data showed that the train entered the Frankford Junction curve, with a maximum authorized speed of 50 mph, traveling at 106 mph. However, presenting only what happened does not explain why the engineer was operating his train twice the safe speed. Corrective actions can best be taken when an investigation can get down to the root cause of the accident to determine why something went so terribly wrong. The NTSB report documents post-accident actions by Amtrak and the Federal Railroad Administration and makes several safety recommendations to prevent similar accidents.
The article states, “We’ve gone from speculation to assertion to confirmation, and we’ve done all this based on ... evidence? Not exactly. Actually, not even close.”
There are always some facts or questions that cannot be fully answered in an accident investigation, including this Amtrak accident. Nonetheless, as evidenced by the NTSB public docket, investigators were able to analyze a tremendous amount of information. This includes the engineer’s training records, rules exams, efficiency testing, performance evaluations, time sheets, medical records from Amtrak and the engineer’s private physician, as well as additional medical evaluations he took at the request of the NTSB. Beyond that, investigators reviewed scientific studies—including research in the areas of situational awareness, distraction and information processing, and prospective memory—to support their analysis. The NTSB determines the probable cause of an accident, and, as necessary, makes recommendations aimed at preventing future accidents. In the Amtrak 188 investigation, we made 14 new recommendations.
The article stated, “Dr. Jenner claims that those (radio) conversations last for 6 minutes, with the final conversation at 21:19:13. Actually, Dr. Jenner is mistaken. The final conversation between SEPTA (Southeastern Pennsylvania Transportation Authority) train 769 and the train dispatcher ... took place at 21:18:01. A subsequent remark, made a minute later-unidentified in origin ... produced the following: Second Person [laughs]: ‘Yeah, we got rocked.’”
The last radio broadcast, as you pointed out, occurred at 21:19:13. There is too much static from that radio broadcast for it to be understood. As a result, the Amtrak engineer would not have known if the transmission originated from the dispatcher or from someone else. Nonetheless, the response was clearly made by the SEPTA engineer, and it is consistent with the SEPTA emergency situation—“We got rocked”—and which makes it likely that the Amtrak engineer was interested in what the SEPTA engineer had to say. Nonetheless, even without that last radio transmission, the SEPTA communication with the dispatcher lasted about 5 minutes, still a significant amount of time to have one’s attention diverted while still attempting to focus on his own train operations.
The article states, “In fact, the event recorder shows that he operated the train at the proper speed ... until, realizing his error, he initiates an emergency brake application.”
While listening to the communications between the SEPTA engineer and the dispatcher, the Amtrak engineer did operate his train at or near track speed. This is not surprising. People who are distracted, for instance, those who drive their cars while on their cell phones or texting, are often able to maintain a legal speed and stay in their lanes for a period of time. Nonetheless, those who are distracted when using cell phones and texting are subject to “cognitive tunneling”—in short, an inattentional blindness phenomenon in which the observer is too focused on instrumentation, task at hand, internal thought, and the like, and not on the present environment. Similarly, though the Amtrak engineer was not on his cell phone, his attention on the SEPTA train caused him to lose focus on other tasks, and not on the present environment. Moreover, distraction research, dating back more than 50 years, has clearly demonstrated its degrading effects on a person’s recall and ability to process information fully. Hence, the report’s conclusion: “The Amtrak engineer accelerated the train to 106 mph without slowing the train for the curve at Frankford Junction, due to his loss of situational awareness, likely because his attention was diverted to the emergency situation with the SEPTA train.” The article presents no alternative explanation.
We share an interest in making the transportation systems in the United States among the safest in the world. In the spirit of mutual understanding, I invite you and your staff to come and visit the NTSB, meet with our investigators and scientists, tour our laboratories, and talk with our Board members. I hope you will accept my invitation and come with an open mind to learn about how the NTSB makes transportation safer for everyone.