Page:Derailment of Amtrak Passenger Train 188 Philadelphia, Pennsylvania May 12, 2015.djvu/52

NTSB ==3. Conclusions==

3.1 Findings
1. None of the following was a factor in this accident: the mechanical condition of the train; a foreign object striking the locomotive; the condition of the track; the weather; medical conditions of the Amtrak engineer; alcohol, other drugs, or any other type of impairment; cell phone use; and fatigue.

2. The Amtrak engineer initially accelerated his train to a high rate of speed in a manner consistent with how he habitually manipulated the controls when accelerating to a target speed, suggesting that he was actively operating the train rather than incapacitated moments before the accident.

3. 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.

4. Training focusing on prospective memory strategies for prolonged, a typical situations that could divert crewmember attention may help operating crews become aware of, and take measures to avoid, errors due to memory failure.

5. Cab signal protection to enforce the 50 mph speed restriction in the eastbound direction at Frankford Junction or a fully implemented positive train control system would have prevented the accident.

6. The Federal Railroad Administration 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.

7. If the passenger car windows had remained intact and secured in the cars, some passengers would not have been ejected and would likely have survived the accident.

8. Passengers were seriously injured by being thrown from their seats when the passenger cars overturned.

9. Although the passenger equipment safety standards in Title 49 Code of Federal Regulations Part 238 provide some level of protection for occupants, the current requirements are not adequate to ensure that occupants are protected in some types of accidents.

10. Matching patient arrival to hospital capacity in a mass casualty incident is crucial to ensuring optimal care can be provided for all patients. 42