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That theory was presented by National Transportation Safety Board Chairman Christopher Hart after the board concluded that a lack of situational awareness by engineer Brandon Bostian caused the derailment that also injured 159 passengers.
The board determined that Bostian’s confusion was “likely because his attention was diverted to an emergency situation with another train.”
Hart speculated that Bostian may have believed he was on a second curve that comes after the Frankford Junction curve, where the speed limit is 50 mile per hour. The limit on that second curve was 110 miles per hour.
“The best that we could come up with was that he was distracted by this radio conversation about the damaged (commuter) train and forgot where he was,” Hart told reporters after the meeting ended. “That was the best conclusion that we could come up with as to why he was trying to accelerate up to 110.”
Bostian’s train roared into the 50 mile per hour curve at 106 miles per hour.
Bostian told investigators that he had no recollection of the seconds just before the wreck.
“Often the individual who is lacking situational awareness is the last one to know it,” Hard said.
Also contributing to the accident was the lack of automatic braking technology known as positive train control, the board found.
During Tuesday’s session, NTSB crash investigator Steve Jenner said Bostian’s attention had been diverted to a problem with a nearby SEPTA commuter train.
That commuter train had been hit by a rock, and its engineer was discussing the incident with his dispatcher over a radio channel Bostian was monitoring.
Shortly after that conversation ended, Bostian ended up accelerating quickly — and mistakenly — out of the initial curve, which had deadly consequences, Jenner said. Had Bostian done the same thing — accelerating at full throttle for 40 seconds — once he cleared Frankford Junction and approached the second curve, Amtrak train 188 would have been fine.
“Had he made it that far, it then would have been appropriate to accelerate his train to 106 miles per hour,” Jenner said.
“And he went in a matter of seconds from distraction to disaster,” said board member Robert Sumwalt. “It’s a very basic error, getting distracted and losing your position.”
“This is a standard human error,” Jenner said in response to Sumwalt.
NTSB officials also repeatedly cited the fact that the automatic braking technology it has been calling for for years was not in place and operating as a backstop for Bostian.
Seven months after the passenger rail line suffered its worst wreck in 22 years, Amtrak flipped the switch to activate the system that could have slowed the speeding train. If PTC had been activated before Bostian allowed the train to hurtle into the bend, the system automatically would have slowed its speed.
Hart said the agency made a complete examination of everything that could have gone wrong.
“We searched for any involvement of drugs, alcohol or fatigue and found none,” Hart said. “We looked at the weather, the locomotive, and the track and determined that this was a good train on good track, with an engineer who was fit for duty, not fatigued, not impaired by drugs or alcohol, and not distracted by a personal electronic device.”
Bostian suffered from a head injury in the wreck and said afterward that he had little memory of the seconds that immediately preceded it.
“It’s not so much the stress of the event as the blow to the head,” said NTSB staff member Mary Pat McKay. “The blow to the head can cause the amnesia.”
Bostian he told investigators that a radio report of rocks being thrown at a commuter train concerned him.
“I wasn’t, you know, super concerned, I don’t think,” Bostian told investigators a year ago in the first of two long interviews with them. “There’s been so many times that I’ve had reports of rocks that I haven’t seen anything, that I felt it was unlikely that it would impact me.”
The wreck of Amtrak train 188 left rail cars strewn like toppled bowling pins beside the Frankford Junction tracks. One ripped open in a contortion of aluminum that left little looking like a rail car. Others, whipped off the tracks at 103 miles per hour, landed on their sides. Passengers hit the ceiling, flew out of broken windows, landed atop one another, were struck by flying luggage or were crushed in the twisted wreckage.
In addition to the eight dead, 46 people were seriously injured and 113 others suffered lesser injuries.
“We’re going to take what the NTSB has told us today and look for improvements at Amtrak,” Amtrak CEO Joe Boardman told reporters after the NTSB board meeting. “We have an excellent training program. We’ll now adjust that based on what the NTSB has said.”
Boardman said Bostian is on leave, declining to say whether it was paid or unpaid. He would not comment on whether Bostian could face criminal charges.
PTC has been called “arguably the single-most important rail safety development in more than a century” by federal regulators.
Federal Railroad Administration head Sarah Feinberg threatened to fine passenger and freight railroads last year when a year-end deadline for its installation approached. But Congress listened to the railroads’ plea and extended the deadline until 2018.
Congress, whose members have received more than $24 million in campaign contributions from the powerful railroad industry since 2008, also said railroads could ask for up to two additional years after the 2018 deadline to complete the job.
Feinberg said her agency continued to push railroads to implement PTC.
“One of the things we’re doing right now is collecting a lot of data from railroads about their progress and then posting it online so that the public can view it,” Feinberg said in an interview after the hearing. “We’re holding railroads feet to the fire.”
Though Amtrak owns most of the rail on which its trains run in the Northeast Corridor, the balance of it’s operations are on track owned by freight rail roads.
“Until PTC is in place we’re always concerned that we’ll be here in this room again looking at another PTC preventable accident,” Hart said.