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Safety Recommendation Details

Safety Recommendation R-09-023
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 ALSTOM SIGNALING, INC.: Assist the Washington Metropolitan Area Transit Authority, and other rail transit operators and railroads that use your audio frequency track circuit equipment, in examining their train control systems for susceptibility to parasitic oscillation and spurious signals capable of exploiting unintended signal paths, and implementing measures to eliminate those adverse conditions that could affect the safe performance of their train control systems. (Urgent) (Superseded by R-10-23 and R-10-25)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Superseded
Mode: Railroad
Location: Washington, D.C., DC, United States
Is Reiterated: No
Is Hazmat: 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Addressee(s) and Addressee Status: Alstom Signaling, Inc. (Closed - Superseded)

Safety Recommendation History
From: NTSB
To: Alstom Signaling, Inc.
Date: 8/10/2010
Response: From the safety recommendation letter to Alstom Signaling, Inc. dated August 10, 2010, and written in response to the June 22, 2009 collision of two Washington Metropolitan Transit Authority (WMATA) metrorail trains near the Fort Totten station. Urgent Safety Recommendation R-09-23, previously classified “Open—Acceptable Response,” is reclassified CLOSED – SUPERSEDED by Safety Recommendation R-10-23, issued to Alstom Signaling Inc., and Safety Recommendation R-10-25, issued to the six other transit agencies that use GRS audio frequency track circuit modules. The NTSB also issued safety recommendations to the U.S. Department of Transportation, the Federal Transit Administration, the Tri-State Oversight Committee, the Washington Metropolitan Area Transit Authority Board of Directors, the Washington Metropolitan Area Transit Authority, the Massachusetts Bay Transportation Authority, the Southeastern Pennsylvania Transportation Authority, the Greater Cleveland Regional Transit Authority, the Metropolitan Atlanta Regional Transportation Authority, the Los Angeles County Metropolitan Transportation Authority, and the Chicago Transit Authority.

From: NTSB
To: Alstom Signaling, Inc.
Date: 4/27/2010
Response: The NTSB appreciates Alstom’s cooperation with the NTSB in its investigation of this accident. As tests continue in your lab and on site at WMATA and other customer locations, the NTSB would like to be kept informed. Pending the results of Alstom’s examination of its automatic train control system for vulnerabilities and its implemention of measures to eliminate those adverse conditions that could affect the safe performance of this train control system, Safety Recommendation R-09-23 is classified OPEN -- ACCEPTABLE RESPONSE.

From: Alstom Signaling, Inc.
Date: 10/20/2009
Response: Letter Mail Controlled 10/22/2009 11:47:33 AM MC# 2090653: - From Neal Illenberg, Site Safety Director: 13. Alstom's Actions Prior To and After the Safety Recommendation: Both prior to and after the issuance of' the Safety Reconzmendation, Alstonl has been assisting both the NTSB and WMATA by exanlining the Sacts surrounding the June 22, 2009 incident. Alstom has devoted substantial resources towards that investigation, including its leading personilel on track sigrtaling equipment. Since that preliminary finding by the NTSB investigatiilg tcatn, Alstoni lias continued to investigate the matter in its own laboratory in Rochester, New Yorli. Alstoln is also continuing to work with WMATA, including additional tcsting of equipment forwarded to our laboratory as well as upcoliling on-site testing in the Washington area. At this point in time, Alstom's testing and evaluation is not complete. With that said, Alstorn can update the NTSB on the following preliminary results of its findings, recognizing that testing and analysis is ongoing. Tile existence of parasitic oscillation in and of itself is not the issue. 'Ilie issue appears to be: (i) whether parasitic oscillation modulates at a frequency that it can generate a spurious signal; (ii) whether there is a path Tor the signal to travel upon, in this case between tile trans~izittera nd receiver; and (iii) whether tlie receiving rnodule is susceptible to that sigtial. We should note that our equipment was originally designed in the 1970s to work with only Alstom equipment. The system was never designed or tested to work with other track signaling equipment. In fact, we have previously xceivcd requests from WMATA to approve the use of mixing Alstom and non-Alstoni track circuit equipment, but have declined to provide such consent since that would require substaiitial tcsting that we have not undertaken or been asked to undertalte. I11 this regard, the NTSB's Safety Recommendation notes: The results of postaccident testing and the ongoing investigation have also raised concerns about how routine track circuit adjustments andlor changes in the operati~lg characteristics of electronic cornponellts in ATC systems may affect systems performance. The modules at the Fort Totten station are original equipment that was manufactured by General Railway Signal and installed when the Red Line was constructed in the 1970s. WMATA maintenance records show that an impedance bond for the track circuit where the accident occurred was replaced 5 days bdore the accident, which required the track circuit signal strength to be adjusted to accommodate the new equipment. Safety Recomlnendatioil at 3 (footnote omitted). We understand that the NTSB is continuing to examine how the nixing of Alstom and non-Alstom equipment may have substantially contributed to the generation of the identified spurious signal and its path and susceptibility. As to the Alstoin equipment, we are continuing to test the track circuit modules for the cause of the parasitic oscillation, the path, and the receiver susceptibility. We are also examining mitigation strategies for each of these elements. We arc conductiily tcsts in our lab and will shortly begin to conduct tests on these issues on site at WMATA and other customer locations. Since our investigation is continuing, we are unable at this time to malce any specific findings or recommendations to either WMATA or our other customers. We will continue, however, to keep the NTSB apprised as our inlvestigation continues.