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Safety Recommendation Details

Safety Recommendation R-10-024
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.: Conduct a comprehensive safety analysis of your audio frequency track circuit modules to evaluate all foreseeable failure modes that could cause a loss of train detection over the service life of the modules, including parasitic oscillation, and work with your customers to address these failure modes.
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):

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 notes that Alstom is 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 will encompass all known and reasonably foreseeable failure modes that could affect the safety of Alstom AFTC modules. Pending completion of the analyses being conducted for all track circuit designs, Safety Recommendation R-10-24 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 is conducting comprehensive safety analyses of all of its Audio Frequency Track Circuits, including a detailed review of the existing safety documentation for each design generation. These safety analyses are being conducted for all track circuit designs in accordance with the component failure mode analysis guidelines outlined in American Railway Engineering and Maintenance-of-Way Association ("AREMA") Manual Part 17 and will encompass all known and reasonably foreseeable failure modes that could affect the safety of Alstom AFTCs.