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Safety Recommendation Details

Safety Recommendation R-16-005
Synopsis: On January 12, 2015, at 3:15 p.m. eastern standard time, Washington Metropolitan Area Transit Authority (WMATA) southbound Yellow Line train 302, with about 380 passengers on board, stopped after encountering heavy smoke in the tunnel between the L’Enfant Plaza station and the Potomac River bridge in Washington, DC. The operator of train 302 told the Rail Operations Control Center (ROCC) that the train was filling with smoke and he needed to return to the station. The WMATA ROCC allowed train 510, following train 302, to enter the L’Enfant Plaza station, which also was filling with smoke. Train 302 was unable to return to the station before power to the electrified third rail, which supplied the train’s propulsion power, was lost. Some passengers on train 302 evacuated the train on their own, and others were assisted in evacuating by first responders from the District of Columbia Fire and Emergency Medical Services Department (FEMS). As a result of the accident, 91 people were injured, including passengers, emergency responders, and WMATA employees, and one passenger died. WMATA estimated the total damages to be $120,000. The National Transportation Safety Board (NTSB) has been concerned with the safety of the WMATA rail system since 1970, when it conducted a special study of the proposed transit rail system while it was still under construction. The resulting report, NTSB/RSS-70/1, Study of Washington Metropolitan Area Transit Authority’s Safety Procedures for the Proposed Metro System, resulted in one safety recommendation to WMATA to “develop the capability within WMATA for system safety engineering and apply system safety principles to all aspects of the proposed [rail] system to identify, assess, and correct those deficiencies identified by the analysis.” This accident is the 13th WMATA rail accident investigated by the NSTB since WMATA rail began operation in 1976. The NTSB has issued 101 safety recommendations to WMATA since 1970.
Recommendation: TO THE DISTRICT OF COLUMBIA OFFICE OF UNIFIED COMMUNICATIONS: Upon completion of action satisfying Safety Recommendation R-16-04, develop call processing standards for the public service answering point (PSAP) to ensure that 911 calls are processed in accordance with those of other comparable PSAPs.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
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: 5/23/2016
Date Closed:
Addressee(s) and Addressee Status: District of Columbia, Office of Unified Communications (Open - Acceptable Response)

Safety Recommendation History
From: NTSB
To: District of Columbia, Office of Unified Communications
Date: 8/10/2018
Response: As discussed above, your FY 2017 OUC PAR shows that you have developed call processing standards, and we note that your CFTF is evaluating the audit results and identifying theimprovements needed to meet the goals that you have established. An acceptable response to Safety Recommendation R-16-4 will require an independent outside audit of your PSAP call processing times and comparison of the audit results to national standards. To satisfy Safety Recommendations R-16-5 and -6, after the audit and comparison needed to satisfy Safety Recommendation R-16-4 is completed, you will need to evaluate and revise the aspects of your PSAP call processing times that are not complying with national standards to bring them into compliance. Pending those actions, Safety Recommendations R-16-5 and -6 are classified OPEN--ACCEPTABLE RESPONSE.

From: NTSB
To: District of Columbia, Office of Unified Communications
Date: 9/15/2016
Response: The National Transportation Safety Board (NTSB) has reviewed the National Highway Traffic Safety Administration (NHTSA) “Request for Information: Nationally Uniform 911 Data Systems,” published at 81 Federal Register 27904 on June 30, 2016. The proposed nationally uniform 911 data system would contain uniform data elements for all computer-aided dispatch (CAD) systems. These self-defining data would facilitate the collection, analysis, and sharing of all CAD data received, collected, processed, and transmitted during 911 calls, including administrative and cost data. These data, in turn, would be made available to all 911 public safety answering points (PSAP) and 911 authorities at the state and local levels. NHTSA poses 15 questions, of which three are applicable to the NTSB. Question 1 addresses significant changes in 911 data systems over the last 10 years, question 2 addresses the usefulness of the data that would be created by implementing a nationally uniform 911 system, and question 3 focuses on the most critical issues facing the current use and interconnection of PSAP CAD systems. Usefulness of Implementing a Nationally Uniform 911 Data System (question 2) The proposed nationally uniform 911 data system would improve the efficiency of NTSB investigations by providing a consistent data format, which would allow us to compare investigative cases, identify trends, and provide more informative evaluations to PSAPs and other stakeholders. Together, these benefits would have a positive effect on our mission to improve transportation safety. The NTSB recently issued safety recommendations to the District of Columbia Office of Unified Communications as a result of our investigation of the January 12, 2015, Washington Metropolitan Area Transit Authority L’Enfant Plaza station electrical arcing and smoke accident: Audit your public service answering point (PSAP) to validate compliance with the standards published by the National Emergency Number Association or another similar standards organization. The audit should (1) determine the average length of time that call takers use to process an emergency call and dispatch emergency service, and (2) compare those results with those of other comparable PSAPs. (R-16-4) Upon completion of action satisfying Safety Recommendation R-16-4, develop call processing standards for the public service answering point (PSAP) to ensure that 911 calls are processed in accordance with those of other comparable PSAPs. (R-16-5) Train call takers for the public service answering point on the standards developed in Safety Recommendation R-16-5, and include the standards in recurrent training. (R-16-6) These three recommendations address system performance relative to comparable PSAPs. Each recommendation is currently classified “Open?Await Response.” Collectively, the intent of the recommendations is to audit PSAP performance, develop call processing standards, and train call takers so that all aspects of public safety response meet a reasonable comparable standard. These recommendations reinforce the necessity for a better understanding of comparable PSAP performance and the integral role of a uniform 911 data system in improving all levels of emergency response.

From: District of Columbia, Office of Unified Communications
Date: 8/17/2016
Response: -From Karima Holmes, Director: ln addition to the D.C. Council Key Performance Indicators related to call processing time standards, the Office of Unified Communications (OUC) has had in place policies and standard operating procedures related to call processing for many years. Each of the following OUC policies and procedures aligns with national standard(s): POLICY NAME EFFECTIVE NATIONAL DATE STANDARD Update of Pro QA Version 11.3 Training 08/15/2006 CALEA4 5.3.7(a) FEMS Mass Casualty Incident 10/25/2006 CALEA 6.9.1, 6.9.2 and 6.9.4 Event Type- INJURY with subtype JOHN/JANE DOE 11/14/2006 CALEA 6.2.4( d) Operations Administration 03/26/2007 CALEA 6. 1.2, 6.1 .3 and 6.1.4 Verification of Addresses and Other Matters 05/31/2007 CALEA 6.2.2 Emergency Messages, Death Notifications and Check the Welfare 06/29/2007 CALEA 6.3.3, 6.3.4 Requests NORAD E9-1-1 Call Handling Protocol for Airborne Airline Event 09/19/2007 CALEA 2.1.4 Incident Address Verification 02/20/2009 CALEA 6.2.3 Caller Management and Customer Service 07/01/2009 CALEA3.6.5 Continuing Dispatcher Education Process, Roles and 07/01/2009 CALEA 3.6.5 Responsibilities Duplicate Incidents: Multiple Callers for Same Events 07/01/2009 CALEA 3.6.5 Emergency Police Dispatcher Certification 07/01/2009 CALEA 3.6.5 Maintaining Current Priority Dispatch Practice Standards 07/01/2009 CALEA 3.6.5 Priority Dispatch System Use 07/01/2009 CALEA 6.1.3 and 6.2.3 Silent Dispatching of Radio Runs via Mobile Data Computer 09/14/2009 CALEA3.6.5 (MDC) or Mobile Data Terminal (MDT) Request for Police & FEMS Calls for Service via Dispatcher Ol/28/2010 CALEA 6.2.3(b) In 2015, OUC initiated a project to review and update all of its policies. The agency engaged a vendor with experience in 9-1-1 operations to assist. The project is ongoing with expected completion through implementation of new policies and standard operating procedures aligned to current national standards by the end of Calendar Year 2016.