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Safety Recommendation Details

Safety Recommendation R-10-018
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 Hazard Identification and Resolution Matrix process in your system safety program plan to ensure that safety-critical systems such as the automatic train control system and its subsystem components are assigned appropriate levels of risk in light of the issues identified in this accident.
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: 7/19/2012
Addressee(s) and Addressee Status: Washington Metropolitan Area Transit Authority (Closed - Acceptable Action)
Keyword(s): Transit,

Safety Recommendation History
From: NTSB
To: Washington Metropolitan Area Transit Authority
Date: 7/19/2012
Response:

From: NTSB
To: Washington Metropolitan Area Transit Authority
Date: 7/19/2012
Response: Because WMATA has completed the requested review and revisions to its system safety program plan, Safety Recommendation R-10-18 is classified CLOSED—ACCEPTABLE ACTION.

From: Washington Metropolitan Area Transit Authority
To: NTSB
Date: 1/13/2012
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-10-015. As requested, WMATA is providing information from the Federal Transit Administration which expressly states, WMATA and the Tri-State Oversight Committee have completed all of the associated recommendations to close out the FTA State Safety Oversight Program Audit, which was issued as a Final Report on March 4, 2010.

From: NTSB
To: Washington Metropolitan Area Transit Authority
Date: 4/5/2011
Response: The NTSB notes that WMATA has revised its SSPP to document the new hazard management approach and that, as of the date of your letter, it was being circulated for internal review. In addition, WMATA is currently revising its Hazard Identification and Resolution Matrix process as a means of implementing the new hazard management approach. Pending completion of WMATA’s Hazard Identification and Resolution Matrix process and update of the SSPP to ensure that safety-critical systems are identified with appropriate levels of risk, Safety Recommendation R-10-18 is classified OPEN – ACCEPTABLE RESPONSE. The NTSB would appreciate receiving a copy of WMATA’s Hazard Identification and Resolution Matrix procedures and SSPP with your response.

From: Washington Metropolitan Area Transit Authority
To: NTSB
Date: 11/4/2010
Response: CC# 201000408: - From Richard Sarles, General Manager: WMATA has reviewed its Hazard Identification and Resolution Matrix process and has collected and reviewed the hazard management processes of more than a dozen peer agencies. The results of these reviews have been used to modify WMATA's own approach to hazard management. WMATA's System Safety Program Plan (SSPP) has been revised to document the new hazard management approach and is currently being circulated for internal WMATA review. In addition, WMATA is currently revising its Hazard Identification and Resolution Matrix Procedure (Procedure #2.1/0) as a means of implementing the new hazard management program approach. Training on the new hazard management approach will be provided to WMATA staff once the procedure is finalized. WMATA has also hosted the Transportation Safety Institute Rail System Safety class (Which addresses hazard management) to provide training to Safety Department staff in the areas of system safety and hazard management.