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Safety Recommendation Details

Safety Recommendation R-10-010
Details
Synopsis: On Monday, June 22, 2009, about 4:58 p.m., eastern daylight time, inbound 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.
Recommendation: TO THE WASHINGTON METROPOLITAN TRANSIT AUTHORITY: Review the process by which Metrorail technical bulletins and other safety information are provided to employees and revise that process as necessary to ensure that (1) employees have received the information intended for them, (2) employees understand the actions to be taken in response to the information, and (3) employees take the appropriate actions.
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: 8/10/2010
Date Closed: 6/27/2013
Addressee(s) and Addressee Status: Washington Metropolitan Area Transit Authority (Closed - Acceptable Action)
Keyword(s): Transit, Training and Education

Safety Recommendation History
From: NTSB
To: Washington Metropolitan Area Transit Authority
Date: 10/23/2013
Response:

From: NTSB
To: Washington Metropolitan Area Transit Authority
Date: 6/27/2013
Response: We are pleased that WMATA has completed action to address this recommendation and has provided examples confirming that information regarding safety procedures has been distributed and acknowledged by employees. Accordingly, Safety Recommendation R-10-10 is classified CLOSED—ACCEPTABLE ACTION.

From: Washington Metropolitan Area Transit Authority
To: NTSB
Date: 6/6/2013
Response: -From James M. Dougherty, WSO-CSSD, Chief Safety Officer: I want to personally thank you for taking the time out of your schedule to meetwith members of my staff on May 23, 2013, to discuss the WashingtonMetropolitan Area Transit Authority's (WMATA), National Transportation SafetyBoard (NTSB) recommendations that are currently classified "Open AcceptableAction". It is my belief that the dialogue, along with the documentation that wasprovided to support the closure of several recommendations, will assist theNTSB in its evaluation of WMATA's progress and move these recommendationsto closure. Enclosed is a listing of all of the items in which closure documentation wasprovided during the meeting. WMATA would like to thank the NTSB for its consideration and support as wecontinue to demonstrate our goal of making safety a top priority for both ouremployees and patrons. We look forward to continued meetings with the NTSBwhere we can exchange technical information in support of our common goal. Provided formalized evidence of the distribution system for technical bulletins and similar, show acknowledgement by employee, checks of the effectiveness of the distribution

From: Washington Metropolitan Area Transit Authority
To: NTSB
Date: 4/3/2013
Response: -From James M. Dougherty, WSO-CSSD, Chief Safety Officer: In collective review of the Washington Metropolitan Area Transit Authority (WMATA) "Open Acceptable" National Transportation Safety Board recommendations, the attached documentation is provided to support the closure of recommendation R-10-010. In the letter dated July 19, 2012, the NTSB requested additional documentation which provides evidence that demonstrates employees are not only provided with new procedures, but they have a clear understanding of the procedures and that the procedure is being implemented. To satisfy this finding , WMATA is providing a copy of a memorandum and supporting documentation that was provided by the Director of the Quality Assurance and Warranty, which outlines procedures that are currently in place to which provides a detailed approach for the application/inspection process along with a signature page for the technician , supervisor and inspector to ensure the procedure is understood. The completion of this modification demonstrates our goal of making safety a top priority throughout the Metrorail system. Please review the enclosed memorandum and supporting documentation, and feel free to contact me.

From: NTSB
To: Washington Metropolitan Area Transit Authority
Date: 7/19/2012
Response: The submitted documentation contains several examples of new test and inspection procedures, and WMATA’s June 10, 2011, letter reports that the procedures have been distributed and signed by employees. However, WMATA does not appear to have ensured that employees understand the new procedures or that the new procedures are being implemented correctly. The NTSB points out that simply ensuring that employees have been given information does not guarantee that the new procedures are clearly understood or are being implemented. Accordingly, pending a further reply from WMATA addressing these concerns, Safety Recommendation R-10-10 is classified OPEN—ACCEPTABLE RESPONSE.

From: Washington Metropolitan Area Transit Authority
To: NTSB
Date: 6/10/2011
Response: CC# 201100318: - From James M. Dougherty, WSO-CSSD, Chief Safety Officer: Consistent with our discussions held on May 3, 2011, in collective review of the Washington Metropolitan Area Transit Authority (WMATA) "Open Acceptable" National Transportation Safety Board recommendations, the enclosed documentation is provided to support the closure of recommendation R-07-024. As requested, WMATA is providing information on our wheel truing procedures, along with examples of audits conducted by the Quality Assurance and Warranty department, whose responsibilities include, verification of accurate wheel truing at all locations.

From: NTSB
To: Washington Metropolitan Area Transit Authority
Date: 4/5/2011
Response: The NTSB notes that WMATA has taken many steps to improve the dissemination of technical bulletins and other safety information to employees and is verifying that employees are in receipt of new information and have a sound understanding of any procedural changes. Pending NTSB’s review of (1) the elements contained in WMATA’s new process for distributing, and its employees’ acknowledging the receipt and understanding of, safety materials and (2) evidence of the process’s effectiveness for ensuring that employees take appropriate action based on the information, Safety Recommendation R-10-10 is classified OPEN – ACCEPTABLE RESPONSE.

From: Washington Metropolitan Area Transit Authority
To: NTSB
Date: 11/4/2010
Response: CC# 201000408: - From Richard Sarles, General Manager: WMATA is dedicated to improving the dissemination of safety-related information throughout the authority. WMATA has taken several integral steps to increase information awareness through the use of the General Manager's Weekly Newsletter, development of the Safety Measurement System, improving the Departmental websites, expansion/development of the Documentum program, and continued improvement of the maintenance management program known as Maximo. WMATA has also developed a series of weekly meetings that bring together members from a variety of operational groups, as well as safety, to discuss ways in which the authority can increase efforts to improve its system. The group also focuses on the development and distribution of technical documents and maintenance procedures. WMATA is also working within each department to ensure that supervisors are verifying that employees are in receipt of new information and have a sound understanding of any procedural changes. As a follow-up to the Authority-wide employee safety culture survey, WMATA is currently in the process of developing an action plan and accompanying communication strategy to increase awareness of the survey findings and action steps.