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Safety Recommendation Details

Safety Recommendation R-09-019
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 FEDERAL TRANSIT ADMINISTRATION: Advise all rail transit operators that use audio frequency track circuits in their train control systems to develop a program to periodically determine that electronic components in their train control systems 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: 5/18/2011
Addressee(s) and Addressee Status: FTA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FTA
Date: 5/18/2011
Response: The NTSB is satisfied that FTA’s September 22, 2009, Dear Colleague letter advised all transit operators of the need for developing a program to determine periodically that electronic components in their train control systems are performing within design tolerances. In addition, a meeting was held on November 12-13, 2009, by FTA-sponsored TCRP Project J-6 Task 77, at which it was decided that a group of transit agency members would be responsible for development of a recommended practice or standard to assist the industry with the necessary requirements for development of an effective loss of shunt detection tool. These combined actions satisfy the recommendation; accordingly, Safety Recommendation R-09-19 is classified CLOSED – ACCEPTABLE ACTION.

From: FTA
To: NTSB
Date: 12/20/2010
Response: CC# 201100012: - From Peter Rogoff, Administrator: In response to this recommendation, FTA has done the following: Issued Dear Colleague Letter On December 13, I sent a letter to all major transit agency Chief Executive Officers (CEOs) stressing the importance of gathering safety information from employees in a non-punitive way (enclosed). I have asked the CEOs to examine their reporting systems and to make every effort to meet the intent of this recommendation. Conducted Industry Outreach We held our first Transit Rail Advisory Committee for Safety (TRACS) meeting in Washington, DC, on September 9-10 where we discussed reporting systems as integral parts of an effective safety management system. The members of TRACS include a number of high level transit officials as well as experts affiliated with labor unions and other transit stakeholders. The TRACS recommendations will assist us with developing a consensus approach to implementing and/or improving reporting programs within transit systems. In addition, we held our 14th Annual State Safety Oversight meeting in Memphis, Tennessee, September 27 through October 1, where we discussed several reporting system models. This meeting was well attended by transit industry personnel as well as representatives of the various states with rail transit safety oversight responsibilities. Notes from the meeting, including information on non-punitive reporting systems, were distributed to all rail transit systems in the United States. Moreover, in early 2011, we will be convening a transit CEO Safety Summit to further discuss this important issue with key stakeholders. The CEO Safety Summit will allow us to speak directly to the CEOs of the major transit systems in the United States who provide the bulk of the almost 10 billion annual transit trips. Results of the Safety Summit will also be distributed widely to all transit providers. Transportation Research Board (TRB) Initiatives As Administrator, I am a member of the project selection committee of the TRB's Transit Cooperative Research Program (TCRP). FTA has championed and is funding two research projects relevant to non-punitive reporting systems: TCRP A-34, Improving Safety-Related Rule Compliance in the Public Transportation Industry and TCRP A..35, Improving Safety Culture in Public Transportation. These projects focus on the challenges of incorporating greater employee participation in ensuring the safety of rail transit operations and maintenance, as well as strategies for overcoming these challenges. Moreover, FTA staff members serve on the panels that are overseeing the development of the projects. In addition, the TRB has issued an interim report for the A-34 project (enclosed) that provides information and guidance for establishing non-punitive reporting systems within transit systems. The interim report also includes an implementation checklist. TCRP disseminates its reports widely to the transit industry. However, to emphasize its significance, I ensured that a link to the interim report was included in my recent Dear Colleague letter to the industry. The A-35 project will develop resources for assessing, improving, and monitoring organization-wide safety culture that promotes safety as a core value and top priority throughout public transportation systems. Organizations with effective safety cultures share a constant commitment to safety as a core value and top priority that permeates the entire organization. Non-punitive reporting systems are a key element of successful safety cultures. FTA will also sponsor a session on transit safety culture at the upcoming TRB Annual Meeting in January 2011. This session-Creating Safety Culture and Management Systems in Public Transportation Agencies-will feature experts discussing how to in1plement positive changes in organizational culture that support safe operations. One of the elements of such an organizational culture involves non-punitive reporting systems. We are pleased that there will be NTSB, board-level participation on the panel. We will also make it a point to distribute information from the panel to the transit industry for the benefit of those who cannot be at the session. Enhanced Track Worker Safety Program FTA also has an initiative underway that provides workshops to the rail transit industry on track inspection techniques and right-of-way safety. FTA will use contractor resources to further support the development of non-punitive reporting systems. Through the special projects element of this contract, FTA is developing a scope of work to provide more focused research on: • Prevalence and type of non-punitive employee safety reporting programs in the rail transit industry; and • Effective practices already used in the rail transit and commuter rail industries to implement non-punitive employee reporting programs. The efforts of this special project will provide FTA with an in-depth look at successful nonpunitive reporting systems and practices, which may benefit peer public transit agencies. FTA will disseminate the results of this work to all major transit agencies when it is complete. Bus Safety and Security Program FTA has also established a framework for improving safety culture within the transit bus industry, including the promotion of nonpunitive reporting systems to foster internal communication of potential safety issues. Through state DOT orientation seminars and voluntary on-site reviews, FTA works with the industry to identify strengths and gaps in safety reporting systems and discusses methodologies for encouraging safety hazard and near-miss reporting by front line personnel. Additionally, the program's resource website, (http://bussafety.fta.dot.gov/splash.php) self-assessment checklist provides questions related to management's role and how to solicit input from employees on safety matters and technical resources to support system development and implementation. I announced the start up of this resource website at the American Public Transportation Association Annual Meeting last year and it has been widely accessed since. Currently, the tally is 695 registered users from 595 different transit agencies. Transportation Safety Institute Training Program (TSI) Additionally, FTA funds extensive safety training for the industry through TSI. Three courses are particularly relevant -Transit System Safety; Rail Transit Incident Investigation; and Transit Industrial Safety Management. The importance of non-punitive reporting systems is stressed in these courses as a means of discovering leading indicators and resolving safety issues before accidents occur. Typically, 446 transit industry and State Safety Oversight personnel complete these courses each year. FTA Audit of TOC and WMATA The NTSB also made recommendations to both TOC and WMATA that they address the recommendations made by FTA as a result of our audit report issued in March 2010. A status on that effort follows.

From: NTSB
To: FTA
Date: 4/27/2010
Response: The FTA’s plan to provide additional guidance regarding the development of a periodic testing program as described in the recommendation is satisfactory; accordingly, pending completion of that action, Safety Recommendation R-09-19 is classified OPEN -- ACCEPTABLE RESPONSE. Also, thank you for including the NTSB in the November 12-13, 2009, meeting with the FTA, the American Public Transportation Association, the Transit Cooperative Research Program (TCRP), and transit agencies. We believe that the meeting helped to improve participants’ understanding of the intent of Safety Recommendations R-09-17 through -19 and will assist the industry in addressing this important issue. We look forward to reviewing documentation of the FTA’s efforts to satisfy Safety Recommendation R-09-19 and the TCRP study, and we commend the FTA for its immediate response to the urgent safety recommendations.

From: FTA
To: NTSB
Date: 11/6/2009
Response: Letter Mail Controlled 11/18/2009 1:23:58 PM MC# 2090687: - From Peter M. Rogoff, Administrator: Thank you for your letter dated September 22 regarding the ongoing investigation of the June 22, 2009, collision between two Metrorail trains on the Washington Metropolitan Area Transit Authority's (WMATA) Red Line. This letter provides you with the status of the Federal Transit Administration's (FTA) activities to address the National Transportation Safety Board's (NTSB) Safety Recommendations R-09-17, R-09-18, and R-09-19, resulting from the Board's investigation of the collision that caused nine fatalities at the Fort Totten Station. On the same day these recommendations were issued, I sent an FTA Dear Colleague Letter advising all fail transit operators of these recommendations and urging them to examine track circuits that may be susceptible to parasitic oscillation and spurious signals capable of exploiting unintended signal paths, and to eliminate those adverse conditions (Enclosure 1). FTA had already begun work with the American Public Transportation Association (APTA) and the Transit Cooperative Research Program (TCRP) on the Board's earlier urgent recommendation (R-09-07) to survey the industry on track circuit monitoring systems in use and plan a meeting with transit signal specialists to discuss the Board's recommendations. The meeting is tentatively scheduled for November 12-13 in Washington, DC. NTSB's staff will be asked to join us. The NTSB staff has met with FTA, APTA personnel, and TCRP consultants to help all parties better understand the recommendations so we can more effectively assist the industry on this important matter. On October 14, I urged the nation's rail transit agencies to respond promptly to the TCRP signal system survey and to participate in the upcoming meeting (Enclosure 2). FTA will also be working with the 27 State Safety Oversight agencies that oversee 47 rail transit systems around the country and asking them to follow up with each transit agency and monitor progress on implementation. We will continue to keep you informed.