NTSB: Amtrak 188 engineer distracted by radio reports in minutes before crash

The National Transportation Safety Board (NTSB) concluded a yearlong investigation into the Amtrak 188 derailment that killed 8 and injured nearly 200 more, finding that the train’s engineer, Brandon Bostian, was distracted at the time of the accident.

In the minutes leading up to the derailment, an Acela train and a SEPTA train both reported being hit by rocks along the route. The NTSB board found that Bostian was distracted by these reports, causing him to lose situational awareness and mistakenly believe he had reached a long straightaway when, in tragic fact, he was accelerating into a very sharp curve. The board also found that a lack of Positive Train Control (PTC), a safety system that has since been activated at the derailement site, was a contributing cause.

Amtrak 188 was travelling 106 miles per hour when it entered the Frankford Junction curve in North Philadelphia. The speed limit for that area of track is 50 miles per hour.

The train’s data showed that 1.5 miles before Frankford Junction, the last in a series of curves Amtrak trains take leaving 30th Street Station, Bostian accelerated the train as though he had already passed the tight turns. Bostian told investigators he realized the train was heading too fast into the curve and applied the emergency brake. The train derailed three seconds later, going 102 miles per hour. Bostian, who sustained a concussion in the accident and said he could not remember the moments before it clearly, said the last thing he remembered was hitting the brakes but knowing he was already too late.

“I remember holding onto the controls tightly and feeling like, OK well this is it. I’m going over,” he told NTSB investigators.

In interviews with the investigators, Bostian said he was very concerned about the SEPTA train, which had reported being hit by rocks thrown by unknown individuals. That caused the SEPTA engineer to “dump” the train, or perform an emergency stop. Bostian was concerned that SEPTA passengers and employees may have deboarded, and told investigators that he repeatedly blew his train’s horn while passing by.

A colleague of Bostian’s had recently suffered a serious eye injury when rocks were thrown at the train he was operating and broke some of the train’s windshield. Momentarily distracted by the reports of other trains in the area being hit by rocks, Bostian simply miscounted the turns, going full throttle too early.

Prior to the accident, Bostian had no issues with his past performance, noted the NTSB investigators, who described him as he was well regarded by his colleagues.

At the time of the derailment, Amtrak engineers had to memorize their routes completely, including speed limits and other standards. Signals inside the locomotive cab and alongside the tracks help, but speed-limit signs were not posted everywhere, including heading into the Frankford Junction curve.

Following the derailment, the Federal Railroad Administration ordered Amtrak to post speed limit signs throughout the Northeast Corridor.

Early on, some media outlets speculated that Bostian might have been using his phone at the time of the crash, but this was quickly squashed when the phone’s data usage confirmed that the phone was on “airplane” mode at the time of the accident. Bostian told investigators that he had his phone stowed away in a bag during the fateful trip. Engineers distracted by texts or mobile games have been to blame for other train derailments, including a deadly 2008 crash outside Los Angeles.

That derailment spurred Congress to pass the Rail Safety Improvement Act, which required all railroads to implement the PTC safety technology. PTC would have prevented Amtrak 188 had it been activated at the time of the accident, but Amtrak was still a few months away from completing installation on this stretch of track. PTC helps prevent human error by automatically slowing trains that are exceeding speed limits or may be approaching another train too quickly.

NTSB officials repeatedly pushed strongly for PTC during the hearing. In questioning Dr. Steve Jenner, one of the lead investigators, about how a single, momentary lapse by the engineer caused the accident NTSB’s Robert Sumwalt said: “When you design a system where a single point failure can lead to disaster, sometimes… you get a disaster. That is why the NTSB has been calling for Positive Train Control for so long, to provide the protective layer of redundancy to keep a single human error from being deadly.”

In opening statements, NTSB Chairman Christopher Hart noted that Congress had extended its original deadline to activate PTC from the end of 2015 to the end of 2018, with an option allowing railroads to apply for an additional two-year extension. “Let us keep in mind that the deadline that matters is not 2018,” said Hart. “The deadline that really matters is the date of the next PTC-preventable tragedy.”

During the hearing, NTSB member T. Bella Dinh-Zarr proposed an amendment to call the lack of PTC as the probable cause of the accident, and demote Bostian’s distraction to just a contributing cause. The NTSB board voted that down, 1 to 3, and intstead adopted language calling Bostian’s speeding, caused by a loss of situation awareness likely due to his attention being diverted to the stopped SEPTA train, the probable cause, and the lack of PTC merely a contributory cause.

Since last year’s accident, Amtrak has installed PTC throughout most of its Northeast Corridor and on trains between Philadelphia and Harrisburg, but most of its remaining lines will take years more before they get the safety technology. Amtrak has not activated PTC on the 56 miles of line between New Rochelle, N.Y. and New Haven, CT, which are controlled by the Metro-North Railroad. SEPTA has already activated PTC on its Warminster line and expects to have all of its regional rail lines using PTC by July. NJ Transit won’t have the system ready until 2018 at the earliest, and freight railroads operating in the area, CSX Transportation and Norfolk Southern, say they may take until 2020.

Only intercity heavy commuter railroads and most freight railroads are required to install PTC. PATCO, subways, trolleys, and light rail lines aren’t required to use the technology. Besides SEPTA and Amtrak, only the Metrolink in Southern California—the inspiration of the federal law—have managed to implement PTC.

PTC only helps prevent accidents caused by human error. Those only make up 35 percent of train crashes, which are exceedingly rare to begin with: less than 4 accidents per 1 million miles traveled. That makes rail one of the safest modes of travel: Of the 34,000 travel deaths in a year, fewer than 800 are related to rail, with most—32,000—related to automobiles. Looking at 2008 data, there were 0.55 deaths per 100 million miles traveled in passenger automobiles, but just 0.13 deaths per 100 million miles traveled in trains.  

Even though it was active at the time, PTC did not prevent the Amtrak collision outside Chester, PA in April that killed two workers and injured 31 aboard the train. There, communications between the workers and Amtrak trains broke down, tragically demonstrating a safety issue unaddressed by PTC.

Freight companies own most of the railroad tracks in the United States. Amtrak itself only owns 3 percent of the lines it uses – it leases the rest from commuter and freight lines. According to the Association of American Railroads, a freight rail industry trade group, freight companies have spent nearly $6 billion implementing PTC and expect to spend another $4 billion more. A Congressional Research Service report in 2012 estimated that full PTC implementation would cost $14 billion.

The NTSB findings also focused on the emergency response by Philadelphia’s first responders to the derailment. Philadelphia’s fire department, police department, and office of emergency management all have separate protocols for responding to mass casualty incidents like the derailment, adding to confusion. Philadelphia police will routinely transport patients to hospitals in police vehicles, an unusual practice that began decades ago and usually reserved for gunshot or stabbing victims who may not have time to wait for an ambulance.

The investigators also found that a window malfunction caused four of the eight passenger deaths: The windows separated from the third car, allowing the passengers to be ejected from the train. A similar malfunction caused four passengers to be ejected and killed in a 2013 derailment in the Bronx on the Metro-North Railroad.

The NTSB findings will have negligible impact on the outcome of lawsuits being brought by the victims and victims’ families. Amtrak has conceded fault; the trial will focus entirely on the question of how to apportion the statutorily capped $295 million. More than 60 lawsuits related to the crash have been consolidated under one federal judge in Philadelphia.