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On Monday, June 22, 2009, about 4:58 p.m., eastern daylight time, inbound Washington Metropolitan Area Transit Authority (WMATA) Metrorail train 112 struck the rear of stopped inbound Metrorail train 214. The accident occurred on aboveground track on the Metrorail Red Line near the Fort Totten station in Washington, D.C. The lead car of train 112 struck the rear car of train 214, causing the rear car of train 214 to telescope1 into the lead car of train 112, resulting in a loss of occupant survival space in the lead car of about 63 feet (about 84 percent of its total length). Nine people aboard train 112, including the train operator, were killed. Emergency response agencies reported transporting 52 people to local hospitals. Damage to train equipment was estimated to be $12 million.
TO THE FEDERAL TRANSIT ADMINISTRATION: Facilitate the development of non-punitive safety reporting programs at all transit agencies to collect reports from employees in all divisions within their agencies and to have their safety departments; representatives of their operations, maintenance, and engineering departments; and representatives of labor organizations regularly review these reports and share the results of those reviews across all divisions of their agencies.
Original recommendation transmittal letter:
Closed - Acceptable Action
Washington, D.C., DC, United States
Collision of Two Washington Metropolitan Area Transit Authority Metrorail Trains Near Fort Totten Station
Addressee(s) and Addressee Status:
FTA (Closed - Acceptable Action)
Safety Recommendation History
We are pleased that the FTA sponsored the development of TCRP Report 149: Improving Safety-Related Rules Compliance in the Public Transportation Industry, which (1) emphasizes the need for a system that is voluntary, non-punitive, and confidential; (2) includes a safety reporting system implementation checklist; and (3) includes the elements of a memorandum of understanding among an organization’s management, the labor union, and the regulatory agency. The publishing of this report satisfies Safety Recommendation R-10-4, which is classified CLOSED—ACCEPTABLE ACTION.
-From Ruth Lyons, Transit Safety & Security Training Specialist: R-10-04 Request that this be considered “closed – acceptable action” Please see the NTSB entry below from 5/18/2011 – statement from NTSB in red…. Pending the completion of the TRB’s Project No. A-34 and the issuance of a final report for facilitating the development of nonpunitive safety reporting systems, Safety Recommendation R-10-4 is classified OPEN – ACCEPTABLE RESPONSE……. It was published in 2011, please see below in red also. -TRB No. A-34 was published in 2011. http://www.trb.org/Main/Blurbs/166125.aspx -Issuance of a final report for facilitating the development of non-punitive safety reporting systems (Close Call Reporting System Implementation Plan) – distributed copy owed to NTSB asap. Pat and Sheryl, thank you for your consideration. I will be available to meet to discuss any of these items. The recommendation on Fatigue/Sleep Apnea Awareness is not listed above as we are still waiting final approval from our Administrator.
The NTSB notes that the FTA has been facilitating the development of nonpunitive safety reporting programs at transit agencies through industry outreach. At the FTA’s first Transit Rail Advisory Committee for Safety meeting, held September 9-10, 2010, reporting systems were discussed as integral elements of an effective safety management system. From September 27 through October 1, 2010, at the FTA’s 14th Annual State Safety Oversight meeting, several reporting system models were discussed, and in mid-2011, at the FTA’s Transit CEO Safety Summit, nonpunitive safety reporting systems will be further discussed with key stakeholders. In addition, the FTA will use a contractor to further support the development of nonpunitive reporting systems. The FTA will disseminate the results of this work to all major transit agencies when it is complete. Finally, the importance of nonpunitive reporting systems is emphasized in three training courses taught at the Transportation Safety Institute as a means of discovering leading indicators and resolving safety issues before accidents occur. The NTSB notes that, on December 13, 2010, the FTA sent a Dear Colleague letter to all major transit agency chief executive officers and published on its website safety reporting system models, that the FTA is studying ways to assist agencies in implementing nonpunitive safety reporting programs. An interim report, titled Improving Safety-Related Rule Compliance in the Public Transportation Industry, has been prepared for the Transit Cooperative Research Program (TCRP), which is administered by the Transportation Research Board (TRB) of The National Academies. This report, which includes an implementation checklist for developing a nonpunitive safety reporting system to help guide in this process, can be accessed online at the TRB’s website, at
. In addition, the FTA is sponsoring TCRP A-35, Improving Safety Culture in Public Transportation, a project to 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. Transit agencies with effective safety cultures share a constant commitment to safety as a core value and top priority that permeates the entire organization, and nonpunitive reporting systems are a key element of successful safety cultures. NTSB Member Robert Sumwalt presented “Investigating and Preventing Organizational Accidents” at the TRB’s 90th Annual Meeting, “Creating Safety Culture and Management Systems in the Public Transportation Agencies” session. This session provided background and context on safety culture, safety management systems, and approaches for enhancing communication and coordination regarding safety issues in the transit industry. Pending the completion of the TRB’s Project No. A-34 and the issuance of a final report for facilitating the development of nonpunitive safety reporting systems, Safety Recommendation R-10-4 is classified OPEN – ACCEPTABLE 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.
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