Good morning and welcome to the Boardroom of the National Transportation Safety Board. I am Christopher Hart, and it is my privilege to serve as Chairman of the NTSB. Joining me are Vice Chairman Bella Dinh-Zarr, Member Robert Sumwalt, and Member Earl Weener.
I would like to welcome to the Boardroom the Chair of the Board of Directors of the Washington Metropolitan Area Transit Authority, or WMATA, Jack Evans; newly appointed WMATA Board Member Robert Lauby; new WMATA General Manager Paul Wiedefeld; and new WMATA Chief Safety Officer Patrick Lavin.
Today, we meet in open session, as required by the Government in the Sunshine Act, to consider the electrical arcing and smoke accident a few hundred feet from the L’Enfant Plaza station on January 12, 2015.
The accident exposed hundreds of people to heavy smoke. Ninety-one people were injured, and tragically, one person died. On behalf of my fellow Board Members and the entire NTSB staff, I offer our condolences to her family and friends. Nothing can replace your loved one, but it is our hope that the report that we consider today will help to ensure safety in WMATA’s rail operations in the future.
We further sincerely hope that the passengers, first responders, and employees affected by this accident have fully recovered, or are on the road to a full recovery.
Many of the people who are here today took the train to the L’Enfant Plaza station, which is just steps away from this Board room. Metrorail riders take more than 700,000 trips each weekday – to and from work and elsewhere. Metrorail serves office secretaries and cabinet secretaries, janitors and senators. The safety of Metrorail is critical both to the daily life of Washington, D.C. and to the effective operation of all branches of the federal and local governments.
Yet the safety of Metrorail was once again brought into question by the accident that we consider today.
In 2009, nine people lost their lives in an accident at WMATA’s Fort Totten station. Our report cited WMATA for a lack of safety culture and for ineffective safety oversight by its governing structure.
WMATA, its Board, and the Tri-State Oversight Committee (or TOC) took several steps that were consistent with the necessary safety improvements. The Department of Transportation, as we recommended, sought the legislative authority to provide safety oversight of rail fixed guideway transportation systems, including the ability to craft and enforce safety regulations and minimum requirements governing operations, track and equipment, and signal and train control systems. We made recommendations to WMATA addressing the specific conditions leading to the Fort Totten Accident, and WMATA acted on many of these recommendations.
Yet since that tragic accident, WMATA’s safety culture and safety oversight have not changed adequately. As a result, the specific hazards that we will consider today were allowed to develop and persist.
WMATA did not adequately mitigate the presence of water in tunnels, despite the role that water can play in the type of accident that we will hear about today. Sealing sleeves that are intended to make cable connectors weather-tight were missing. The smoke detector nearest the event was inoperable. Ventilation procedures were incomplete, and worse yet, those procedures were poorly understood by employees. WMATA’s Rail Operations Control Center was poorly prepared to respond to this scale of emergency, and radio communication problems that were well known had not been addressed.
Less than a month after the fatal L’Enfant Plaza accident, we issued six urgent recommendations to WMATA, the Federal Transit Administration, and the American Public Transportation Association to address the state of good repair of tunnel ventilation systems, written emergency procedures, training for fire and smoke events, and verification that best practices were being followed.
In June 2015, we issued recommendations to WMATA relating to the construction and installation of power cable connector assemblies, with an emphasis on weather-tight seals that prevent intrusion by moisture and other contaminants.
The scenario was familiar: After the 2009 Fort Totten collision we found proximate causesspecific to that accident. We issued recommendations, some of them urgent, to mitigate specific hazards that should not have been allowed to develop.
In part to learn more about the current safety culture at WMATA and the state of WMATA’s rail safety oversight, last June we convened a two-day investigative hearing. A disturbing picture emerged: many of the same organizational and oversight shortcomings that we cited in 2009 continue to plague WMATA. Little or no progress has been made toward building a meaningful safety culture.
The TOC was no more able to enforce corrective action in 2015 than it was in 2009. Despite new authorities, the FTA remained – and remains – averse to crafting and enforcing safety regulations and minimum requirements regarding operations, track and equipment, and signal and train control systems. The FTA continues to rely on state safety oversight agencies and local transit systems to create their own rules and to determine what constitutes effective inspection and enforcement. In WMATA’s unique case, state-level oversight depends on statutory agreement among three jurisdictions. By all accounts, its state safety oversight organization, the TOC, has been ineffective.
That’s why we issued urgent recommendations in September to effectively transfer the rail safety oversight of WMATA to the Federal Railroad Administration (or FRA).
WMATA needs a regulatory structure with rules, inspections and enforcement. FRA can provide all three.
This is the thirteenth NTSB investigation of an accident on Metrorail, and the ninth since 2004. Prior to today’s investigation, we have issued 101 safety recommendations to WMATA.
The NTSB’s mission is to derive safety lessons from accident investigations and to make recommendations to prevent recurrences. However, when the NTSB finds itself issuing a continuous stream of accident reports to address the basic safety management of a single transit rail system, something is fundamentally flawed; Here, that something is safety oversight.
Strong safety oversight is a critical pillar of an effective safety culture that makes it possible to learn safety lessons and act on them before accidents occur.
In WMATA’s case, safety oversight responsibility is shared by three jurisdictions – Maryland, Virginia, and the District of Columbia. This model is unique in transit rail and thus far has proven uniquely dysfunctional.
In the seven years since Fort Totten, these three jurisdictions have been unable to create an effective oversight body; safety still is not institutionalized as a core value at WMATA.
It is encouraging that the WMATA Board supported Mr. Wiedefeld’s recent decision to close the Metrorail system for emergency inspections in the aftermath of a similar electrical arcing event at the McPherson Square station. Mr. Wiedefeld was not confident that safety improvements to the electrical system had truly been implemented. His actions were consistent with deep concern for the safety of WMATA’s Metrorail riders.
But this one-day inspection action is not enough. Nor are months of safety-centered actions at WMATA in the wake of an accident. Nor is the FTA’s “safety blitz.” Nor is action toward resolving the hundreds of corrective actions that the FTA and the TOC have identified.
Taken together, all of the actions and plans that we have seen to date are necessary but not sufficient for long-term safety improvement.
Only robust, permanent safety oversight can assure that positive safety improvements will become the norm, and continue to be the norm, throughout WMATA’s rail operations.
It is time to embrace systemic changes to establish safety as a core value at WMATA, system-wide, on an ongoing basis. The traveling public deserves no less.
Now Managing Director Tom Zoeller will introduce the staff.