The NTSB has released the docket of the factual information it has developed in its investigation into the May 12, 2015 derailment of Amtrak #188 in Philadelphia, Pennsylvania.
It's a big file, containing 164 items and over 2200 pages of information, bulked up by over 500 pages from the NORAC operating rule book and the NEC employee timetable.
Let me be the first to admit I have not read all 164 items, and all 2200+ pages.
I have read the Signal Group's factual report.
I have read the Track and Engineering Group's factual report.
I have read all the information pertaining to or including event recorder data from locomotive 601 of train 188, including comparisons with event recorder data from locomotive 635.
I have read all the reports regarding mechanical inspections and operation of the locomotive.
I have read all the interviews with crew members, operating officers, train dispatchers, and crew members of other trains operating in this section of the NEC at or near the time of the derailment.
I have read the medical reports and the hours of service records of #188's crew.
I've read the report of the Operations Group and I've looked at the videos from the cameras on-board a SEPTA train.
I've even read item 155, the radio transcripts of communications of the Philadelphia fire department personnel responding to the accident.
The NTSB docket is released with the following advisory:
The public docket contains only factual information collected by NTSB investigators, and does not provide analysis, findings, recommendations or probable cause determinations. No conclusions about how or why an accident occurred should be drawn from the docket. The docket opening marks a transition in the investigative process where the majority of facts needed for the investigation have been gathered and the NTSB can move ahead with analysis of those facts. Opening the docket affords those with a need and desire for its contents the opportunity review what factual information has been gathered about the accident. Any analysis, findings, recommendations, or probable cause determinations related to the accident will be issued by the Board at a later date.
That's more than boilerplate. That's NTSB preserving, isolating, its evaluation process from its investigative process, so as not to prejudice either, and good for the NTSB, but...
But if the release of the docket indicates a transition point has been reached where NTSB has sufficient factual material to shift from investigation to analysis and cause determination, then it is imperative that gaps, lapses, omission in the factual material so gathered be identified and questioned.
For example, I read item 155 hoping there might be some transcription of radio transmissions between/among Amtrak's train dispatcher overseeing this section of the railroad (Section 6) and the trains operating in that section.
Much has been made of the railroad communications that night, with a crew member of #188 clearly recalling that locomotive engineer of that train reported being stoned or "shot at" directly in the vicinity of a SEPTA train that was stopped after having been struck by an object that shattered its windshield.
I had hoped to see the transcript of all radio communications in Section 6 from say the time #188 entered that section until the time of the accident.
I couldn't find any such transcripts.
The interview with #188's locomotive engineer made it clear just how little he could recall of the accident itself. That's understandable. There's shock, trauma, and an impact injury to his head.
Prior to the accident, the last things he recalls are sounding the horn while passing North Philadelphia station; advising the SEPTA train crew that he was operating on track 2 adjacent to their train ["hot rail on 2"]; and activating the bell on his locomotive as he approached and passed the SEPTA train.
The engineer does recall placing #188 into emergency braking, which is critically important as he gives us an "end point" so to speak for memory gap. And it makes the data extracted for other sources, i.e. radio communications and event recorders so essential.
The event recorder on locomotive 601, however, was not recording data that would indicate throttle position, the engineer's request for the application or reducion in power. That's a pretty important channel to have operative.
Microprocessor based event recorders with a self-monitoring feature that verifies that all the data required by federal regulation are being recorded are not subject to testing and inspection unless there is an indication of failure displayed or a download taken within the preceding 30 days reveals a failure to regularly recurring data elements, so.... So we might want to find out if the event recorder on this locomotive was self-monitoring and if it indicated any failure......not that the condition of the event recorder has any bearing on the accident itself.
However, in developing the factual information necessary to make an analysis, it is crucial to know if it is possible to interpolate throttle position from other data recorded by the system-- tractive effort, change in speed. In the released documents, there is no indication of NTSB recognizing the need to develop this interpolation.
Everything obtained in the factual information indicates that an investigation and determination into the parameters for, and the actual operation, of the alerter system is of vital importance.
The alerter system "queries" the locomotive engineer with set frequency to confirm that the locomotive engineer is in fact conscious, and cognizant regarding the locomotives movement.
According to FRA regulations any locomotive that is initially placed into service on or after June 10, 2013, used as a controlling locomotive and operated at speeds greater than 25 mph must be equipped with an alerter that has a warning timing cycle, and audio alarm at the expiration of the timing cycle interval, and a visual indication to the engineer at least 5 seconds prior to an audio alarm.
In addition, the alerter warning timing cycle interval must be within 10 seconds of the setting calculated by used the formula where TC (Timing Cycle) = 2400/train speed (mph). So for 80 mph operation, the timing cycle interval must be no less frequently than once every 40 seconds and no more frequently than once 20 seconds.
After January 1, 2017, these requirements apply to any and all locomotives used as a controlling locomotive and operating at speeds in excess of 25 mph. Now the first batch of ACS 64 locomotives were placed into revenue service in February 2014.
However, there is no description of the alerter or its operation on these locomotives in the NTSB reports. There is merely a report on the "self-test" of the alerter to determine if the system is capable of initiating an penalty brake application. In the interview of #188's locomotive engineer, there is no discussion of the alerter function prior to the accident.
The regulation requires that the alerter shall be tested prior to departure from each initial terminal by allowing the warning timing cycle to expire that results in a penalty application. There is no factual information developed on Amtrak's requirement or procedure for complying with this requirement. There is no document included in the docket describing the locomotive engineer's responsibility for testing the alerter when taking charge of a train, if in fact Amtrak does make the engineer the responsible party.
In order to transition from fact gathering to interpretation and determination, we need to know:
1) was the alerter system on locomotive 601 working
2)had it been properly tested before its initial dispatchment
3)was the engineer of #188 required to test the alerter prior to departure from DC
4) what is the warning interval cycle for operation at 60 mph, 80 mph, 100 mph.
5)did the engineer report or experience any anomalies with the alerter system.
Why is this important. It's not important. It's more than important. It's positively vital.
Examination of the event recorder data of locomotive 601 on train #188 confirms that the engineer did sound the horn when passing North Philadelphia station, and did activate the bell when passing the disabled SEPTA train. That action occurs approximately 165 seconds prior to the derailment (Figure 2. Amtrak 601's locomotive event recorder parameters, 12 minutes).
When compared to the data taken from the event recorder on locomotive 635, operating May 10, 2015 over the same route, in the same direction (Figure 1. Amtrak 601 and Amtrak 635 Event Recorder Data from Philadelphia, PA Station to Trenton, NY Station), it is evident that the locomotive engineer on #188 began his acceleration from 60 mph to 80 mph at the proper location.
The engineer on #188 initates this acceleration at 21:19: 20 hours, approximately 85 seconds after deactivating the bell after passing the disabled SEPTA train. We know therefore that the locomotive engineer is operating his train properly and was not disabled by any external force or shock received when passing through teh "stoning zone."
It is only in the last 78 seconds of operation, when demand for tractive effort is maintained rather than decreased; as the locomotive continues to accelerate rather than decelerate for the curve at Frankford Jct, prior to the engineer placing initiating emergency braking that calls into question the condition, awareness, and consciousness of the locomotive engineer.
In these last 78 seconds a functioning alerter interval warning cycle would require two or three or four responses by the locomotive engineer indicating his consciousness and responsiveness to the train's operation, in order to prevent the system from automatically applying the train brakes.
The event recorder indicates the alerter system did not initiate a penalty brake application.
If the alerter system was engaged, and was operating a proper warning interval cycle, then the cause of this derailment will be directly evident.
February 2, 2016
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