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Accident Report Detail

 
Washington Metropolitan Area Transit Authority L’Enfant Plaza Station Electrical Arcing and Smoke Accident

Executive Summary

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.

Our investigation of this accident revealed a range of safety issues and conditions at WMATA that illustrate the transit organization’s lack of a safety culture:

  • WMATA response to smoke report. A smoke detector near the location of the heavy smoke activated at 3:04 p.m. but was not displayed at the ROCC because of a loose wire that prevented communication with the Advanced Information Management System. Other nearby smoke detectors activated later, and those were displayed at the ROCC, but WMATA had no procedures for response to smoke detector activations. WMATA’s standard operating procedure states that at the first report of smoke, all trains should be stopped in both directions, but this did not happen on the day of the accident. Instead, the ROCC told the operator of a train carrying revenue passengers to look for smoke, which was WMATA’s routine response to reports of smoke or fire.
  • Tunnel ventilation. The WMATA station and tunnel ventilation systems were designed in the 1970s when no industry standard existed for emergency ventilations for subway transit systems. The systems were designed for heat removal and temperature control, not for emergency smoke removal. Over the years since WMATA began operation, several studies have identified the need for emergency smoke removal and have recommended increasing the capacity of ventilation fans. Investigators learned that control operators in the ROCC were not trained on strategies for configuring station and tunnel ventilation fans, and therefore, on the day of the accident, the under-platform fans in the L’Enfant Plaza station were turned on in exhaust mode, blanketing train 302 in smoke and pulling smoke into the station.
  • Railcar ventilation. WMATA did not instruct train operators how to shut down the railcar ventilation systems because there was no written procedure. In addition, operators had to ask the ROCC for permission to shut them down, and then the ROCC provided the specific steps to the train operators. However, those steps did not shut down all the ventilation systems on all the cars immediately. Therefore, on the day of the accident, smoke was pulled into most of the railcars on train 302 through the fresh air intakes.
  • Emergency response. On the day of the accident, the District of Columbia Office of Unified Communications, which maintains the 911 emergency call system, was slow in processing the first 911 call reporting the smoke. First responders reported that when they arrived at the L’Enfant Plaza station, they were directed to the wrong tunnel to look for train 302. Evacuating passengers reported that egress through the tunnel was difficult because of dim lighting and obstacles along the safety walkway. The FEMS incident commander appeared to ignore the WMATA Metro Transit Police incident commander and did not take into account the multiple agencies involved in the response and the consequent need for elevation to a Unified Command structure.
  • Oversight and Management. In the years since the 2009 accident at Fort Totten, substantial improvements have not been made, and many of the same safety management deficiencies remain today. The Tri-State Oversight Committee (TOC) has lacked sufficient resources, technical capacity, and enforcement authority to provide the level of oversight needed to ensure safety at WMATA. The TOC also has not met the requirements of the Moving Ahead for Progress in the 21st Century Act that was enacted in 2012. This accident also identified deficiencies in the safety oversight of WMATA by the Federal Transit Administration.

Probable Cause

The National Transportation Safety Board determines that the probable cause of the Washington Metropolitan Area Transit Authority L’Enfant Plaza station electrical arcing and smoke accident was a prolonged short circuit that consumed power system components resulting from the Washington Metropolitan Area Transit Authority’s (WMATA) ineffective inspection and maintenance practices. The ineffective practices persisted as the result of (1) the failure of WMATA senior management to proactively assess and mitigate foreseeable safety risks and (2) the inadequate safety oversight by the Tri-State Oversight Committee and the Federal Transit Administration. Contributing to the accident were WMATA’s failure to follow established procedures and the District of Columbia Fire and Emergency Medical Services Department’s being unprepared to respond to a mass casualty event on the WMATA underground system.


Accident Location: Washington , DC    
Accident Date: 1/12/2015
Accident ID: DCA15FR004

Date Adopted: 5/3/2016
NTSB Number: RAR-16-01
NTIS Number: PB2016-103217

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