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Safety Recommendation Details

Safety Recommendation R-15-012
Synopsis: On January 12, 2015, at 3:15 p.m., eastern standard time, southbound WMATA Metrorail train 302 stopped after encountering heavy smoke in a subway tunnel between L'Enfant Plaza station and the Potomac River Bridge. One passenger fatality and 86 persons transported.
Recommendation: TO THE AMERICAN PUBLIC TRANSPORTATION ASSOCIATION: Urge your members to conduct regular training exercises that use written ventilation procedures to provide ample opportunities for employees and emergency responders to practice those procedures. (Urgent)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Railroad
Location: Washington, DC, United States
Is Reiterated: No
Is Hazmat: No
Accident #: DCA15FR004
Accident Reports: ​Preliminary Report: WMATA Smoke and Electrical Arcing Accident in Washington, DCWashington Metropolitan Area Transit Authority L’Enfant Plaza Station Electrical Arcing and Smoke Accident
Report #: RAR-16-01
Accident Date: 1/12/2015
Issue Date: 2/11/2015
Date Closed: 4/7/2016
Addressee(s) and Addressee Status: American Public Transportation Association (Closed - Acceptable Action)

Safety Recommendation History
From: NTSB
To: American Public Transportation Association
Date: 4/7/2016
Response: We understand that, in addition to issuing the requested alerts to your members, you added this issue to your 2015 rail conference as a special, one-of-its-kind session named Systems Assurance Trifecta, and included the issue for discussion at the June 21, 2015, Rail Safety Committee meeting. These actions satisfy the intent of Safety Recommendations R-15-11 and 12, which are classified CLOSED--ACCEPTABLE ACTION.

From: American Public Transportation Association
Date: 3/14/2016
Response: -From Michael P. Melaniphy, President and CEO: About APTA The American Public Transportation Association (APTA) is a non-profit international trade association of public and private member organizations, including public transit systems; high-speed intercity passenger rail agencies; planning, design, construction and finance firms; product and service providers; academic institutions; and state associations and departments of transportation. More than ninety percent of the 10.7 billion of Americans who use public transportation are served by APTA member transit systems. As the primary advocacy group for public transportation in North America, we fully appreciate and accept as our primary duty to lead the industry in moving people safely. This safety and security role is deeply imbedded in the over 100 year history1 of our organization and is exemplified as being the top goal of APTA’s Strategic Plan. Status of Recommendations R-15-11 and R-15-12, Electrical Arcing, Smoke and Evacuation (Urgent) In addition to our usual practice of issuing alerts to our members whenever the NTSB issues safety recommendations that could be applicable to operational safety, even if they are intended for a single agency rather than the industry at large, APTA also moved quickly to add this topic to our agenda for the APTA Rail Conference as a special, one of a kind session which we named a “Systems Assurance Trifecta”. For a detailed summary of each session within the Safety Trifecta please use this URL:, June 23. The following description was extracted from the program: Systems Assurance Trifecta NEW! Tuesday, June 23 Electrical arcing, smoke conditions in a tunnel, and emergency response The Systems Assurance Trifecta event is a new concept for APTA’s Rail Conference. The intent is simulate a real event that resulted in a cascading system failure event and model it from several different points of view in sequential conference sessions. The objective is to provide a greater understanding on how the base event could recur in similar situations at other rail agencies; offer the best approaches to identifying the event precursors; and discuss solutions involving systems engineering, systems safety, systems maintenance, and operational resilience that mitigate the risk of occurrence and/or the consequences of such an event. Though each of the three conference sessions may stand alone, when connected, they provide a greater understanding of how complex systems can be overwhelmed by sequences of events affecting operational functions, physical design limits, or the organizational command and control structure. This Systems Assurance Trifecta is based on incidents which have occurred within our industry involving electrical arcing events impacting traction power, creating smoke conditions that must be addressed with appropriate ventilation, and carrying out emergency response functions to evacuate customers at platform and track levels. SESSION 1 Electrical Arcing, Smoke & Fire: Managing the Risk -- Tuesday, 8:30 - 10 a.m. Session 1 of the three-session trifecta covers electrical systems designs on various types of traction power and high voltage systems and the types of precautions taken to ensure safe grounding, bonding, and arc prevention. Case histories of smoke and fire events from electrical sources will also be covered. SESSION 2 Tunnel Ventilation Systems -- Tuesday, 10:30 a.m. - 12 p.m. Session 2 looks at ventilation and fire-life safety designs in subsurface guideways. The discussion focuses on the choice of appropriate standards and the effects of tunnel design configurations on risk reduction for new construction or upgrades to legacy systems. SESSION 3 What Have We Learned about Emergency Preparedness? -- Tuesday, 2:30 - 4 p.m. Session 3 reviews lessons learned from recent fire-life safety events and the adequacy of emergency preparedness plans in developing readiness to handle these complex events when they occur. Included will be the importance of emergency drills and exercises to test both the successful application of prevention systems and ways to change tactics when those systems fail. The three-session trifecta highlights the importance of the knowledge provided from each session to (1) raise awareness of how weak signals and small cracks in control measures of complex social-technical systems have the potential to create havoc on safety or mission critical functions, (2) how they can be identified, and (3) create solutions. Additional follow up action was taken by including this recommendation for discussion at the 2015 APTA Rail Safety Committee meeting held in Salt Lake City June 21, 2015. It is our contention that we have more than satisfied the Board’s recommendation and respectfully request R-15-11 and R-15-12 to be reclassified as “Closed – Acceptable Action”. In closing we wish to affirm to the Board our industry’s commitment to continuously improving towards a goal of safety excellence, which is one which we believe that you also share. We believe that we have demonstrated, though the above actions and not just words or platitudes. We have been diligent to the commitment to strengthen and enhance safety which has been in place for over 100 years. We value the safety and security of our employees, our customers and the public and embrace that responsibility as our highest duty. Thank you for your unwavering dedication to making public transit and other modes of transportation safer for all of us.

From: NTSB
To: American Public Transportation Association
Date: 10/27/2015
Response: We expect to receive an initial response from recipients of our recommendations within 90 days after recommendations are issued, and within 30 days in the case of urgent recommendations; completing actions to address our safety recommendations usually takes recipients 3 to 5 years. Safety Recommendation R-12-36 is now over 3 years old, yet we have received no update regarding your actions to address it since your June 28, 2012, letter. We classified this recommendation “Open—Acceptable Response” on August 22, 2012, pending issuance of the recommended guidelines and standards. To date we have received no response from you regarding Safety Recommendation R-14-71 or Safety Recommendations R-15-6, -11 or -12, currently classified OPEN--AWAIT RESPONSE. Accordingly, we would appreciate receiving a prompt update regarding your actions and plans for satisfying 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, all the recommendations will retain their current classifications. Copies of our letters issuing each of these recommendations are enclosed, as are copies of your June 28, 2012, letter regarding Safety Recommendation R 12-36 and our August 22, 2012 reply.