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Safety Recommendation Details

Safety Recommendation R-09-016
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: Develop a program to periodically determine that electronic components in your train control system are performing within design tolerances.
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: 9/22/2009
Date Closed: 1/21/2014
Addressee(s) and Addressee Status: Washington Metropolitan Area Transit Authority (Closed - Acceptable Action)
Keyword(s): Transit, Positive Train Control

Safety Recommendation History
From: NTSB
To: Washington Metropolitan Area Transit Authority
Date: 1/21/2014
Response: We are pleased that WMATA developed Automatic Train Control (ATC) 1000, 2000, and 3000 procedure manuals, and that ATC-1000 Test 1012 series and Test 1013, and ATC-3000 3005 series procedures were developed to satisfy Safety Recommendation R-09-16. Accordingly, this recommendation is classified CLOSED—ACCEPTABLE ACTION.

From: Washington Metropolitan Area Transit Authority
To: NTSB
Date: 12/9/2013
Response: To satisfy this finding, WMATA is providing copies of Automatic Train Control (ATC)-1 000, 2000 and 3000 procedure manuals that we believe are responsive to this recommendation. The procedures that specifically address this recommendation are ATC-1000 Test 1012 series and Test 1013, and ATC-3000 3005 series procedures. The completion of these manuals and the maintenance and testing practices that have been developed, demonstrates our commitment of making safety the top priority throughout the Metrorail system.

From: NTSB
To: Washington Metropolitan Area Transit Authority
Date: 10/23/2013
Response: We encourage you to submit your reply regarding actions to address Safety Recommendations R-08-4, R-09-16, R-10-12, R-10-13, R-10-16, R-10-17, R-10-20, R-10-21, and R-10-22 at the following e-mail address: correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response.

From: NTSB
To: Washington Metropolitan Area Transit Authority
Date: 12/29/2010
Response: In a June 11, 2010, letter to the NTSB, WMATA described the testing procedures it has developed in T-163—GRS ATP Module Parasitic Oscillation Test, but it did not specify periodic testing to detect changes in the operating characteristics of electronic components within the track circuit modules. Instead, the procedure is to be carried out “as directed.” The text of the document states that the procedure “or a portion or a variation” of it will be incorporated into “the future periodic maintenance program.” The NTSB concludes that, although WMATA Metrorail automatic train control test procedure T163, developed since this accident, will permit technicians to detect the presence of parasitic oscillation like that found in the failed track circuit modules at Fort Totten, unless these procedures are carried out on a periodic basis, an unsafe condition may exist for some time before being discovered and corrected. On June 26, 2010, NTSB staff received an e-mail from the WMATA safety department that stated the following: The “As Directed” trigger in original procedure was for original system wide sweep of affected track circuits and associated circuits identified by the LOS [loss of shunt] Tool process. The PMI T163 was recently signed off and is performed on a six month interval. Several track circuit PMI’s also reference this procedure and may trigger use of same, as may the LOS Business Process used twice daily to monitor the system. However, on August 9, 2010, at a meeting of WMATA’s Board of Directors and the five Board members of the NTSB, you stated the following: With respect to inspection of track circuit modules, beginning in November we will increase the frequency of our inspections on audio frequency track circuit modules within the rail system from annual to quarterly inspections. We will continue the loss of shunt review twice daily until the testing is completed on the real-time alert system and we can implement it. Accordingly, pending receipt of further information from WMATA with regard to its plans for developing a periodic preventive inspection and maintenance program to monitor the operating tolerances of the electronic components in the train control system, Safety Recommendation R-09-16 remains classified OPEN -- ACCEPTABLE RESPONSE.

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 Jnly 27, 2010, these recommendations will be discussed at the NTSB's Board Meeting regarding onr 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 created a new protocol for train control equipment testing. Enclosed is the Preventative Maintenance Instruction (PMI) developed to test for parasitic oscillation. The standard set of PMI's will remain in place to be performed as required to ensure system performance in all other areas.

From: NTSB
To: Washington Metropolitan Area Transit Authority
Date: 4/27/2010
Response: The NTSB understands that WMATA has added procedures to address this recommendation. We would like to receive a copy of the program you have devised to test periodically the train control system to determine whether it is performing as designed. Pending the NTSB’s review of WMATA’s completed written procedures for establishing whether electronic components are performing within design tolerances, Safety Recommendation R-09-16 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 already has an existing set of track circuit periodic testing procedures. These procedures have recently been revised adding another six procedural steps to specifically address this recommendation. In addition, WMATA has also begun developing test criteria to monitor track signal conditions from the carborne environment.