Page:Derailment of Amtrak Passenger Train 188 Philadelphia, Pennsylvania May 12, 2015.djvu/29

NTSB accident/incident report form (FRA form 6180.54) includes fields indicating how many crewmembers were on the train at the time of the accident. The form, however, provides insufficient information about the accident circumstances to determine if the accidents could have been prevented by a second crewmember. More important, it does not provide information about how many crewmembers were in the controlling cab.

Therefore, the NTSB concludes that the FRA accident database is inadequate for comparing relevant accident rates based on crew size because the information about accident circumstances and number of crewmembers in the controlling cab is insufficient. Accordingly, the NTSB recommends that the FRA modify form 6180.54 (Rail Equipment Accident/Incident Report) to include the number of crewmembers in the controlling cab of the train at the time of an accident (R-16-33). The NTSB further recommends that after form 6180.54 is modified as specified in Safety Recommendation R-16-33, the FRA use the data regarding number of crewmembers in the controlling cab of the train at the time of an accident to evaluate the safety adequacy of current crew size regulations. To the extent that two-person crews are relied upon as a means of ensuring speed and signal compliance, it is important to continuously emphasize the need for crew resource management (CRM) training to ensure that crews make the best use of both crewmembers and minimize the risks inherent in relying on two-person crews. Since 1973, the NTSB has been concerned about the quality of interaction among crewmembers in the cab of a locomotive. Following a June 25, 1973, accident in which a Southern Pacific freight train rear-ended another freight train in the rail yard in Indio, California, the NTSB recommended that the Southern Pacific Transportation Company—

"Train all new employees including brakemen in their responsibilities and duties so that they understand their responsibility to monitor the performance of other employees and to take positive action when the situation warrants. (R-74-11)"

Another example occurred on March 25, 1998, when southbound Norfolk Southern Corporation train 255L5 struck the side of eastbound Conrail train TV 220 at a railroad crossing at grade in Butler, Indiana. The Norfolk Southern conductor was killed; the engineer and student engineer sustained minor injuries. The investigation showed that the crewmembers had received the proper signals and alerts to stop the train before reaching the other train; however, they did not work together to comply with those signals and alerts. 19