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Safety Recommendation Details

Safety Recommendation R-09-006
Details
Synopsis: On Monday, June 22, 2009, about 4:58 p.m., eastern daylight time, southbound Metrorail train 112 was travelling in a curve when it struck the rear end of train 214 before reaching the Fort Totten station. Train 214 had stopped before entering the station to wait for another train to leave the platform. The striking train was not equipped with onboard event recorders that would have recorded train speed and other parameters. There was no communication between the train operators and the Metrorail Operations Control Center before the collision. During the collision, the lead car of train 112 telescoped and overrode the rear car of train 214 by about 50 feet. Examination of the track and wreckage indicated that the emergency brake on train 112 was applied before impact. The District of Columbia Fire and Emergency Medical Service reported 9 fatalities and transported about 52 persons to local hospitals. Although the NTSB’s investigation is ongoing and no determination of probable cause has been reached, investigators have concerns regarding the safety redundancy of WMATA’s train control system, which has prompted issuance of this urgent safety recommendation.
Recommendation: TO THE WASHINGTON METROPOLITAN AREA TRANSIT AUTHORITY: Take action to enhance the safety redundancy of your train control system by evaluating track occupancy data on a real-time basis in order to detect losses in track occupancy and automatically generate alerts. Alerts should prompt actions that include immediately stopping train movements or implementing appropriate speed restrictions to prevent collisions. (Urgent)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Railroad
Location: Washington, D.C., DC, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA09MR007
Accident Reports: Collision of Two Washington Metropolitan Area Transit Authority Metrorail Trains Near Fort Totten Station
Report #: RAR-10-02
Accident Date: 6/22/2009
Issue Date: 7/13/2009
Date Closed: 7/19/2012
Addressee(s) and Addressee Status: Washington Metropolitan Area Transit Authority (Closed - Acceptable Action)
Keyword(s): Positive Train Control, Transit

Safety Recommendation History
From: NTSB
To: Washington Metropolitan Area Transit Authority
Date: 7/19/2012
Response: Because WMATA’s publication of its newly developed Automatic Train Control-Track Circuit Monitoring tool manual satisfies Safety Recommendation R-09-6, this recommendation is classified CLOSED—ACCEPTABLE ACTION.

From: Washington Metropolitan Area Transit Authority
To: NTSB
Date: 3/26/2012
Response: -From James M. Dougherty, WSO-CSSD, Chief Safety Officer: In collective review of the Washington Metropolitan Area Transit Authority (WMATA) "Open Acceptable" National Transportation Safety Board recommendations, the enclosed documentation is provided to support the closure of recommendation R-09-006. To satisfy this finding, WMATA is providing our newly developed Automatic Train Control-Track Circuit Monitoring (ATC- TCM) Tool Manual. As you may recall, a demonstration of the Loss of Shunt technology was provided to the NTSB in December of 2011. Since that time, the technology has been enhanced. This tool uses the data gathered by the Advanced Information Management (AIM) computer to identify track circuits that are not performing as expected. This tool is used to monitor the performance of track circuits and assess their ability to provide reliable automatic train protection. Please review, and feel free to contact me should any additional clarification be required.

From: NTSB
To: Washington Metropolitan Area Transit Authority
Date: 12/30/2009
Response: The NTSB notes that, because WMATA determined that no commercial system is currently available that would satisfy the intent of the recommendation, WMATA has developed its own technology, the loss of shunt tool. In addition, WMATA has been reviewing the loss of shunt information twice a day to guarantee the integrity of train control operations and to enhance safety for its customers. The NTSB also notes that WMATA is talking with vendors experienced in developing safety-redundant systems similar to that which WMATA needs. Pending completion of WMATA’s efforts to develop a real-time redundancy system that detects loss-of-shunt and automatically generates alerts to slow or stop trains to prevent collisions, Safety Recommendation R-09-6 is classified OPEN -- ACCEPTABLE RESPONSE. We urge WMATA to continue to make these efforts a top priority and look forward to receiving updates as further progress is made to address Safety Recommendation R-09-6.

From: Washington Metropolitan Area Transit Authority
To: NTSB
Date: 9/9/2009
Response: Letter Mail Controlled 9/10/2009 8:52:16 AM MC# 2090569: - From John B. Catoe, General Manager: This letter is to formally notify you of the actions the Washington Metropolitan Area Transit Authority (WMATA) has taken for the National Transportation Safety Board's Recommendation (R-09-6) (Urgent). WMATA has begun the process of implementing the NTSB's recommendations regarding back-ups to the Metrorail automatic train control system. We took immediate action upon receipt of the NTSB's July 13, 2009 letter to WMATA, which included the urgent safety recommendation to enhance the safety redundancy of WMATA's train control system by evaluating track occupancy data on a real-time basis in order to detect losses in track occupancy and automatically generate alerts (that should prompt actions that include immediately stopping train movements or implementing appropriate speed restrictions to prevent collisions). Because no commercial systems currently available could provide the Metrorail system with the kind of alerts that the NTSB has recommended, we immediately started the processes necessary to develop such a system. Your staff is aware of activities we have and are taking to follow up on the July 13, 2009 NTSB letter. As the urgent recommendation states, The NTSB believes that software algorithms or additional circuitry could be developed to continuously evaluate the validity of real-time track occupancy data and alert operations personnel when problems are detected. WMATA is unique in terms of infrastructure, vehicles, and operations, and for this reason there is no off the shelf back-up train control system. (For example, because of significant differences between the heavy rail systems of WMATA and San Francisco's Bay Area Rapid Transit, the back-up system developed for BART would not meet WMATA's unique needs.) Since the off-the-shelf technology does not exist, WMATA has already developed its own technology, known as the loss of shunt tool. As you are aware, since the June 22nd accident, we have been reviewing the loss of shunt information much more frequently. We now do so twice a day to better safeguard our patrons. This is a top priority, and we are currently in the process of communicating with vendors that have the expertise needed to help us develop this back-up system. The safety of our customers and our employees remains our prime concern, so please be assured that WMATA will continue to devote all of its resources to implementing the NTSB's recommendation as soon as possible.