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Safety Recommendation Details

Safety Recommendation R-09-015
Details
Synopsis: On Monday, June 22, 2009, about 4:58 p.m., eastern daylight time, southbound WMATA Metrorail train 112 was traveling in a curve when it struck the rear end of Metrorail train 214 before reaching the Fort Totten station. 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 52 persons to local hospitals.
Recommendation: TO THE WASHINGTON METROPOLITAN AREA TRANSIT AUTHORITY: Examine track circuits within your system that may be susceptible to parasitic oscillation and spurious signals capable of exploiting unintended signal paths, and eliminate those adverse conditions that could affect the safe performance of your train control system. This work should be conducted in coordination with your signal and train control equipment manufacturer(s). (Urgent) (Superseded by R-10-8)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Superseded
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: 9/22/2009
Date Closed: 8/10/2010
Addressee(s) and Addressee Status: Washington Metropolitan Area Transit Authority (Closed - Superseded)
Keyword(s): Transit, Signals

Safety Recommendation History
From: NTSB
To: Washington Metropolitan Area Transit Authority
Date: 12/29/2010
Response: On July 27, 2010, the NTSB held a Sunshine Act Meeting to discuss the collision of two WMATA Metrorail trains near the Fort Totten station, in Washington, DC, on June 22, 2009. As a result of the adoption of the railroad accident report, the NTSB issued Safety Recommendations R-10-8 through -22 to WMATA on August 9, 2010. Safety Recommendation R-09-15, previously classified "Open-Acceptable Response," was reclassified CLOSED -- SUPERSEDED with the issuance of Safety Recommendation R-10-8, stated below. R-10-8 Because of the susceptibility to pulse-type parasitic oscillation that can cause a loss of train detection by the Generation 2 General Railway Signal Company audio frequency track circuit modules, establish a program to permanently remove from service all of these modules within the Metrorail system.

From: Washington Metropolitan Area Transit Authority
To: NTSB
Date: 7/23/2010
Response: MC# 2100264 - From James Dougherty, Chief Safety Officer: Metro will continue to expeditiously work toward eliminating conditions that could affect the safe performance of train control systems. Metro will also establish a program to periodically determine that our electronic components in the train control systems are performing within design tolerances. As requested, we will continue to update you on our progress.

From: NTSB
To: Washington Metropolitan Area Transit Authority
Date: 7/15/2010
Response: The NTSB appreciates receiving the information you provided regarding action that WMATA has taken to address Safety Recommendations R-09-15 and -16. On July 27, 2010, these recommendations will be discussed at the NTSB's Board Meeting regarding our investigation into the Fort Totten collision. Accordingly, pending that discussion, Safety Recommendations R-09-15 and -16 remain classified OPEN – ACCEPTABLE RESPONSE.

From: Washington Metropolitan Area Transit Authority
To: NTSB
Date: 6/11/2010
Response: Letter Mail Controlled 6/23/2010 12:26:18 PM MC# 2100218: - From Richard Sarles, General Manager: The office of Engineering and Support Services (ENSV) has completed testing of all track circuits of the same make and year as the problematic track circuit identified per the June 22, 2009 investigation. Since the discovery and replacement of four additional bonds/modules, ENSV has not discovered any further bonds/modules that exhibited the same parasitic oscillation. Although there were no other bonds/modules that exhibited these symptoms ENSV, as a precautionary method, replaced four bond/modules that returned data that was within standards, but not satisfactory to ENSV.

From: NTSB
To: Washington Metropolitan Area Transit Authority
Date: 4/27/2010
Response: The NTSB notes that, since August 2009, WMATA engineering and support staff have developed a loss of shunt test procedure that has found four additional track circuit modules that were at risk and that these modules have been replaced. We also note that WMATA is continuing to work with Alstom as testing and data compilation continue. Pending completion of the recommended action, Safety Recommendation R-09-15 is classified OPEN -- ACCEPTABLE RESPONSE.

From: Washington Metropolitan Area Transit Authority
To: NTSB
Date: 10/23/2009
Response: Letter Mail Controlled 10/26/2009 1:05:09 PM MC# 2090656: - From John B. Catoe, General Manager: WMATA's Response: Since early August 2009, WMATA Engineering and Support Services (ENSS) staff has been examining track circuits found to have timing issues. A test procedure has been developed by this group using the LOS (Loss of Shunt) business process. This process has identified four track circuit modules, which have been replaced for exhibiting symptoms similar to the failure mode, one at B06 - Fort Totten (not the incident track circuit), one at B07 - Takoma, and two at C04 - Foggy Bottom. Based on our examination and analyses, WMATA has developed a possible design correction to the Alstom track circuit design which has been demonstrated to Alstom engineers. However, while Alstom Signaling has concurred with WMATA's ENSS group test procedures, they have not fully concurred with this group's final analyses and are requiring that much more extensive testing be performed and more data compiled before granting approval to the design correction. Additional testing has been scheduled for October 26, 2009. WMATA staff will meet at Alstom's headquarters for any additional reviews. WMATA will continue to work with Alstom to develop and deploy a correction to the track circuit design as well as to examine track circuits for any other adverse condition that may affect the performance to the train control system.