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Safety Recommendation Details

Safety Recommendation R-10-023
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 ALSTOM SIGNALING, INC.: Develop and implement periodic inspection and maintenance guidelines for use by the Washington Metropolitan Area Transit Authority and other rail transit operators and railroads equipped with General Railway Signal Company audio frequency track circuit modules and assist them in identifying and removing from service all modules that exhibit pulse-type parasitic oscillation in order to ensure the vitality and integrity of the automatic train control system.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
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:
Addressee(s) and Addressee Status: Alstom Signaling, Inc. (Open - Acceptable Response)
Keyword(s): Positive Train Control

Safety Recommendation History
From: NTSB
To: Alstom Signaling, Inc.
Date: 8/20/2015
Response: Concerning Safety Recommendation R-10-23, we were encouraged by your development of an inspection procedure to verify that Alstom’s Generation 2 AFTC modules are operating within acceptable parameters and do not exhibit pulse-type parasitic oscillation. We are aware that you have conducted on-site testing of all Generation 2 AFTC modules at railroad and rail transit agencies equipped with GRS AFTC modules and, to ensure the integrity of the ATC system, have assisted in removing from service all modules that exhibit pulse-type parasitic oscillation. We are also aware that, while Alstom representatives were on site at railroad and other rail transit properties, they tested Generations 3 and 4 AFTC modules, if such track circuits were in use. We are encouraged that Alstom completed a preliminary review of the test data, notified its customers of the results, and developed periodic inspection and maintenance guidelines for its AFTC customers. We stated in our last letter that we are interested in learning whether these periodic inspection and maintenance guidelines have been issued to, and are being used by, your AFTC customers. Concerning R-10-24, we are aware that Alstom was conducting comprehensive safety analyses of all of its AFTC modules in accordance with the component failure mode analysis guidelines outlined in American Railway Engineering and Maintenance-of-Way Association Manual, Part 17, and planned to encompass all known and reasonably foreseeable failure modes that could affect the safety of Alstom AFTC modules. On February 7, 2011, pending completion of the actions described above, Safety Recommendations R-10-23 and -24 were classified “Open?Acceptable Response.” Completing actions to address our safety recommendations usually takes recipients 3 to 5 years, and these recommendations are now 5 years old. To date, we have received no further information about Alstom’s progress in addressing Safety Recommendations R-10-23 and 24. Accordingly, we would appreciate receiving a prompt update on your plans and actions to satisfy these recommendations. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. Pending your timely reply, Safety Recommendations R 10-23 and -24 will retain their current classification.

From: NTSB
To: Alstom Signaling, Inc.
Date: 2/7/2011
Response: The NTSB is encouraged by Alstom’s development of an inspection procedure to verify that its Generation 2 AFTC modules are operating within acceptable parameters and do not exhibit pulse-type parasitic oscillation. We note that Alstom has conducted on-site testing of all Generation 2 AFTC modules at railroad and rail transit agencies equipped with GRS AFTC modules and, to ensure the integrity of the ATC system, has assisted in removing from service all modules that exhibit pulse-type parasitic oscillation. The NTSB also notes that, while Alstom representatives were on site at railroad and other rail transit properties, Alstom also tested Generations 3 and 4 AFTC modules, if such track circuits were in use. Alstom has completed a preliminary review of the test data, has notified its customers of the results, and has developed periodic inspection and maintenance guidelines for its AFTC customers. The NTSB is interested in learning whether these periodic inspection and maintenance guidelines have been issued to, and are being used by, Alstom’s AFTC customers. Pending completion of the recommended action, Safety Recommendation R-10-23 is classified OPEN -- ACCEPTABLE RESPONSE.

From: Alstom Signaling, Inc.
To: NTSB
Date: 11/5/2010
Response: CC# 201000412: - From Ian de Souza, President and CEO: Alstom has developed an inspection procedure for verifying that its Generation 2 Audio Frequency Track Circuits (AFTC) are operating within acceptable parameters. Using this procedure, Alstom has conducted on-site testing of all Generation 2 AFTC currently in use at all of its U.S. customers to verify proper shunting of the track circuit. 1 (Alstom has not conducted such tests at WMATA as WMATA has advised that it has conducted its own inspection and test of all of its Alstom Audio Frequency Track Circuits and removed from service any suspect track circuits.) While on site, Alstom also tested Generation 3 and 4 AFTC if such track circuits were also in use at the customer location. Alstom has completed a preliminary review of the test data for each of these customers and has advised its customers of any track circuits that exhibit anomalies warranting further investigation and correction. Alstom has also developed inspection and maintenance guidelines for its AFTC customers to enable them to conduct periodic inspections and tests of these track circuits in the future and identify and remove from service any track circuit exhibiting anomalies, including pulse-type parasitic oscillation. If a customer desires, Alstom will conduct training on the use and implementation of these guidelines. Should any customer prefer that Alstom perform all or part of the periodic inspections, testing or analysis, Alstom will work with that customer to develop a mutually acceptable plan to do so.

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.