Remarks as prepared for delivery.
Good morning and thank you for being here. I’m Jennifer Homendy, Chair of the NTSB. With me is Joe Gordon, Supervisory Rail Accident Investigator in charge of this investigation.
Today, the NTSB released the final report of our investigation into the derailment of a Washington Metropolitan Area Transit Authority (WMATA) train near Rosslyn Station in Arlington, Virginia, on October 12, 2021. The train was carrying 187 passengers at the time.
As we stated shortly after the incident — and as you’ll see in this brief video — our investigation determined the wheels on the fourth rail car of train 407 migrated outward to the point where they exceeded the width of the track. This caused the train to derail three times and rerail twice on the same day.
I’ll have additional comments after this video. Let’s watch.
As with any NTSB investigation, the key isn’t determining what happened, which we know pretty early on, but how it happened — that is how we prevent future incidents and tragedies.
But once we issue recommendations, those recommendations must be act on. Otherwise, safety isn’t assured.
Since 1982, the NTSB has investigated 15 accidents on the WMATA rail system. In total, we’ve issued 125 safety recommendations to WMATA. The oldest of these recommendations dates back to 1970 — when the system was still under construction. Let me read it to you:
“Develop the capability within your organization for system safety engineering and apply system safety principles to all aspects of the proposed rail system to identify, assess, and correct those deficiencies identified by the analysis.”
Since that recommendation was issued in 1970, we’ve consistently identified WMATA’s failure to adequately assess and mitigate safety risks; WMATA’s poor safety culture; and the failure of our Federal government to oversee, regulate, and enforce safety on our nation’s public rail transit systems, which are responsible for safely transporting millions of passengers daily.
WMATA alone transports an average of 287,000 people every day.
I want to read you one more line. It’s from our investigation into the 2009 Fort Totten tragedy, which killed nine people and injured 52 others:
“Shortcomings in WMATA’s internal communications, in its recognition of hazards, its assessment of risk from those hazards, and its implementation of corrective actions are all evidence of an ineffective safety culture within the organization.”
That line could very well apply to the accident we’re discussing today.
In fact, it’s been the same story again and again and again since 1970.
In case after case, WMATA struggles to proactively identify safety hazards, including low-probability, high-consequence risks. When they do identify hazards, they’re not communicated within the organization. Mitigations are put into place. But then those mitigations are not monitored or measured for effectiveness. And the hazards themselves aren’t tracked to see if there’s a trend.
This accident is no exception.
Our investigation found that WMATA has known since at least 2014 about the risk of wheel migration in the legacy fleet, which pre-dated the 7000-series fleet. WMATA contracted a study to evaluate the issue in 2015. While that was underway, they began receiving the 7000-series cars.
WMATA then identified wheel migration in the 7000-series beginning in March 2017. Three months later, WMATA changed its “spec” to address the wheel migration issue by increasing the mounting forces on the wheelset.
At the time they adopted the new spec, WMATA had already received 493 railcars out of a total of 749 in the 7000-series. Instead of replacing the wheelsets to the new specs, as they’re doing today, they chose to leave 66% of the 7000-series rail cars with the old spec in service, including this rail car, and put the rest under the new spec. What that means is the 7000-series railcars had two different standards:
- 493 railcars met the old spec;
- 255 met the new spec.
But WMATA continued to see wheel migration on railcars that were in service and transporting passengers even after the entire fleet was in operation:
- Four wheelsets in 2017;
- One in 2018;
- Four in 2019;
- Four in 2020; and
- Eighteen in the first 10 months of 2021 leading up to the derailment.
That’s a total of 31 wheelsets.
Post-derailment, WMATA identified an additional 50 wheelsets that were out-of-spec as a result of our investigation.
Had WMATA conducted a trend analysis to ensure the risk mitigations were effective, this incident could have been prevented.
Let me repeat that: this incident was 100% preventable. There are no accidents in transportation.
But it only takes one to result in a catastrophic event like we saw in Fort Totten in 2009…or like we saw nine years ago in L’Enfant Plaza beneath this building. I’ll note the anniversary of that tragedy, which killed one person and injured 91 others, is next week.
I want to make something clear. When you read this report, you’ll see that the WMATA leadership at the time said they knew nothing about the wheel migration issue.
THAT is a safety culture problem.
I say this often. I’ll say it again: Human error is a symptom of a system that needs to be redesigned. And when it comes to WMATA, they need to be proactive, not reactive.
Especially when you consider it took three rail transit controllers over three hours to realize the train was in the tunnel and the exhaust fan at Rosslyn Station needed to be activated due to protect passengers from smoke. As a reminder, the person who died in the L’Enfant Plaza accident died as a result of smoke inhalation.
WMATA has addressed this particular issue and I commend Randy Clarke for that. But this incident is part of a larger and concerning trend of failing to proactively identify risk and ensure mitigations are actually improving safety.
NTSB has investigated 85 rail transit accidents since 1967, which have resulted in 70 deaths and more than 2,600 injuries.
Operators are absolutely responsible for ensuring safety of their systems.
But when they can’t or won’t, it’s up to Federal or state governments to act.
The 2015 Fixing America’s Surface Transportation Act (FAST Act) gave the U.S. Department of Transportation (USDOT), and particularly the Federal Transit Administration (FTA), the authority to regulate and enforce safety standards for public transit systems.
To this date, they have absolutely failed to exercise that authority.
I will note that the FAST Act also stated that, in exercising that authority, USDOT should consider relevant NTSB recommendations — recommendations asking USDOT to act: to regulate and enforce transit safety going all the way back to 1978.
And yet, here we are today with unenforceable, voluntary safety standards in the National Public Transportation Safety Plan.
As a result, there are no enforceable Federal standards for the Washington Metrorail Safety Commission to hold WMATA accountable.
Let me put a finer point on this.
If I wanted to haul a freight train full of coal through West Virginia today, there are tons of Federal standards I’d have to abide by. The publication containing them is inches thick.
But, if I want to operate a transit train loaded with passengers at rush hour in the nation’s capital, there are no Federal minimum safety standards required.
None.
FTA’s failure to take their authority seriously is evident in their party submission, which states the following:
“It would be our recommendation to NTSB to prevent similar events to encourage all transit agencies operating heavy rail transit cars exceeding 20,000 lbs. to increase the interference fit and press-force on wheelsets to freight-rail industry standards.”
You don’t need to recommend it. You don’t need to encourage it. You need to MANDATE it — just like we do in all other modes of transportation: aviation, marine, pipeline, highway, freight and intercity passenger rail.
I’m calling on FTA to take immediate action to regulate and enforce safety on our nation’s public transit rail systems.
Before I take questions, I do want to acknowledge the parties to the investigation. And I want to thank them for the corrective actions they’ve already taken:
- The Federal Transit Administration;
- The Washington Metrorail Safety Commission;
- The Washington Metropolitan Area Transit Authority;
- Kawasaki Rail Car, Inc., the railcar manufacturer;
- ORX, the wheelset manufacturer; and
- The Amalgamated Transit Union.
Finally, I want to acknowledge the heroes in these incidents and accidents: the responders. Without them, the NTSB’s work would not be possible. In this incident, I’d like to thank the Arlington Country Fire Department and the Metro Transit Police Department.
I’d be happy to take questions.
