Railroad Accident Report: Board Meeting - Miami, FL/Miami-Dade Airport Transit Shuttle Crash

On November 8, 2011, the National Transportation Safety Board held a Board Meeting to discuss and adopt the Railroad Accident Report relating to the Board Meeting - Miami, FL/Miami-Dade Airport Transit Shuttle Crash, which occurred on November 28, 2008.

NTSB public events are also streamed live via webcast. Webcasts are archived for a period of three months from the time of the meeting. Webcast archives are generally available by the end of the event day for public Meetings, and by the end of the next day for Technical conferences.

Synopsis

This is a synopsis from the Safety Board's report and does not include the Board's rationale for the conclusions, probable cause, and safety recommendations. Safety Board staff is currently making final revisions to the report from which the attached conclusions and safety recommendations have been extracted. The final report and pertinent safety recommendation letters will be distributed to recommendation recipients as soon as possible. The attached information is subject to further review and editing.

EXECUTIVE SUMMARY

About 4:44 p.m., eastern standard time, on November 28, 2008, a three-car train operating along a fixed guideway on Concourse E at Miami International Airport near Miami, Florida, failed to stop at the passenger platform and struck a wall at the end of the guideway. Although a maintenance technician was monitoring train operations from the lead car of the train when the accident occurred, the train was operating in fully automatic mode without a human operator. The maintenance technician and five passengers on board the train were injured in the accident. One person on the passenger platform also required medical attention.

As a result of its investigation of this accident, the NTSB makes Safety Recommendations to the U.S. Department of Transportation, to all 50 states and the District of Columbia, to Miami-Dade County, and to Johnson Controls, Inc. The NTSB also reiterates a previously issued safety recommendation to the U.S. Department of Transportation.

CONCLUSIONS

The south train failed to make a normal deceleration and stop at its station platform berthing point because of the failure of a crystal within the program stop system module.

Had it not been bypassed by placement of a jumper wire as part of a troubleshooting process, the overspeed/overshoot relay on board the south train would have functioned as designed when the program stop module failed and the overspeed/overshoot system would have intervened to safely stop the train and prevent the accident.

Johnson Controls, Inc., had no formalized procedures with regard to train maintenance and operations, with the result that the south train was allowed to operate without a vital backup safety system that could have prevented the accident.

The state of Florida and the Miami-Dade Aviation Department failed to exercise effective safety oversight of the Miami International Airport automated people mover system, which resulted in trains being allowed to operate in regular passenger service with a vital safety system disabled.

A lack of state and Federal safety oversight of fixed guideway transit systems can permit those systems to operate with ineffective safety standards, which could, in turn, lead to failures of safety-critical operations and procedures.

PROBABLE CAUSE

The National Transportation Safety Board determines that the probable cause of this accident was the installation by Johnson Controls, Inc., maintenance technicians of a jumper wire that prevented the overspeed/overshoot system from activating to stop the train when the crystal within the primary program stop module failed. Contributing to the accident were (1) the failure of Johnson Controls, Inc., to provide its maintenance technicians with specific procedures regarding the potential disabling of vital train control systems during passenger operations, (2) ineffective safety oversight by the Miami-Dade Aviation Department, (3) lack of adequate safety oversight of such systems by the state of Florida, and (4) lack of authority by the U.S. Department of Transportation to provide adequate safety oversight of such systems.

RECOMMENDATIONS

As a result of its investigation of this accident, the National Transportation Safety Board makes the following safety recommendations:

New Recommendations

  1. To the U.S. Department of Transportation:
  2. Working with the 50 states, identify all fixed guideway transportation systems within each state. (R-11-XX)
  3. To the 50 States and the District of Columbia:
  4. Working with the U.S. Department of Transportation, identify all fixed guideway transportation systems within your jurisdiction. (R-11-XX)
  5. Obtain the statutory authority to provide safety oversight of all fixed guideway transportation systems that operate within your jurisdiction, regardless of their funding authorization or the date they began operation. (R-11-XX)
  6. To Miami-Dade County:
  7. Develop and implement a system safety program plan to identify and manage safety hazards on all fixed guideway transportation systems within your jurisdiction. (R-11-XX)
  8. To Johnson Controls, Inc.:
  9. Implement procedures to prohibit the deactivation of safety-critical systems on fixed guideway transportation systems in passenger service on all properties maintained by Johnson Controls, Inc. (R-11-XX)

Previously Issued Recommendations Reiterated in This Report

To the U.S. Department of Transportation:

  1. Continue to seek the authority to provide safety oversight of rail fixed guideway transportation systems, including the ability to promulgate and enforce safety regulations and minimum requirements governing operations, track and equipment, and signal and train control systems. (R-10-3)