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Safety Recommendation Details

Safety Recommendation R-13-037
Synopsis: Angels Flight is a funicular railway located in downtown Los Angeles, California. Two cars operate on a 33% inclined guide way by means of a mutually connected wire rope for a travel distance of about 300 feet. Power is supplied from a station house at the top of the guide way. An operator collects revenue, and observes and controls movement from a booth at the top of the system. Movement can be commanded by the operator in either automatic or manual mode. Design speed is 3.5 miles per hour. At about 11:30 a.m. September 5, 2013, the downward-moving car derailed near the mid-point of the guide way. There was one passenger aboard that car and five passengers aboard the upward-moving car. The operator recognized that the car stopped but was unaware that it had derailed. He initiated manual operation to attempt to berth the cars at their respective gates. Both cars moved about 100 feet, but stopped short of their gates. The operator then reversed the direction of the cars in an attempt to berth the cars. The derailed car moved uphill toward mid- point and again stopped. The operator then recognized a derailment had occurred and notified senior Angels Flight management of the derailment. Angels Flight did not notify the National Response Center, nor did they call 911 for assistance with evacuating the passengers. A citizen notified the fire department of the accident. The NTSB investigated a prior collision on the Angels Flight Railway that occurred February 1, 2001, which resulted in a passenger fatality.1 The NTSB determined that the probable cause of that accident was the improper design and construction of the Angels Flight funicular drive and the failure of various organizations involved in that design and construction to ensure that the railway system conformed to initial safety design specifications and known funicular safety standards.
Recommendation: TO THE CALIFORNIA PUBLIC UTILITIES COMMISSION: Before authorizing it to resume passenger service, independently verify that the Angels Flight Railway meets all applicable accepted industry standards and engineering practices including: (1) preventing excessive wheel and track wear; (2) providing emergency stopping under all foreseeable failure modes; (3) ensuring safety systems are not bypassed; (4) preventing passenger ejection in the event of a collision; and, (5) providing a suitable means of emergency egress for passengers and ingress for emergency responders. (Urgent)
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Railroad
Location: Los Angeles, CA, United States
Is Reiterated: No
Is Hazmat: No
Accident #: DCA13FR011
Accident Reports: ​Angels Flight Railway Derailment
Report #: RAB-14-02
Accident Date: 9/5/2013
Issue Date: 10/4/2013
Date Closed:
Addressee(s) and Addressee Status: State of California, Public Utilities Commission (Open - Acceptable Response)

Safety Recommendation History
From: NTSB
To: State of California, Public Utilities Commission
Date: 7/15/2015
Response: We note that your February 12, 2015, Resolution ST-170 - Angels Flight, (1) requires the Angels Flight Railway Company to file a Safety Certification Plan and a Safety Certification Verification Report prior to resuming revenue service according to the requirements in General Order 164-D and (2) requires the Safety Certification Plan to include a commitment to implementing all the safety recommendations that the NTSB has issued to Angels Flight. These actions support the intent of Safety Recommendation R-13-37; pending the completion by Angels Flight Railway of these requirements prior to resuming revenue service, the recommendation is classified OPEN—ACCEPTABLE RESPONSE.

From: State of California, Public Utilities Commission
Date: 2/12/2015
Response: -From Paul W. King, PhD, Deputy Director, Office of Rail Safety, Safety and Enforcement Division, California Public Utilities Commission: Please see the attached CPUC resolution, ST-170, which sets forth the requirements for Angels Flight to complete before it will receive CPUC permission to return to service. PUBLIC UTILITIES COMMISSION OF THE STATE OF CALIFORNIA, Safety and Enforcement Division, Rail Transit Safety Branch, Resolution ST-170, February 12, 2015 RESOLUTION RESOLUTION ST-170 ORDERING THE ANGELS FLIGHT RAILWAY COMPANY TO FILE A SAFETY CERTIFICATION PLAN AND A SAFETY CERTIFICATION VERIFICATION REPORT UNDER THE PROVISIONS OF GENERAL ORDER 164-D. Summary This resolution affirms the requirement for the Angels Flight Railway Company to file a Safety Certification Plan and a Safety Certification Verification Report according to the requirements in General Order 164-D, and ratifies California Public Utilities Commission President Michael Peevey’s directive by letter of November 8, 2013, to Angels Flight Railway Company.1 The Safety Certification Plan must include a commitment to implement all the recommendations issued by the National Transportation Safety Board and subsequently directed by President Peevey. Prior to resuming revenue service, a Safety Certification Verification Report must be filed and approved according to General Order 164-D and as ordered herein. Background Angels Flight is a landmark funicular railway that was originally built in 1901 in the Bunker Hill region of downtown Los Angeles. Since 1997, Angels Flight has been effectively owned by the Angels Flight Railway Foundation (Foundation) through a 99-year long-term ground lease with the Community Redevelopment Agency of the City of Los Angeles (CRA/LA). The Angels Flight Railway Company (AFRC) operates Angels Flight on behalf of the Foundation. Between 1901 and 1969, Angels Flight was owned by six different entities. CRA/LA was the eventual owner of Angels Flight and dismantled the funicular in 1969. In 1996, after 27 years of storage, CRA/LA oversaw the project to restore and reconstruct Angels Flight. The funicular was reopened to the public after being reinstalled two blocks south of its 1969 location. The track structure was rebuilt and the drive system was redesigned. In 2001 the redesigned drive system failed, resulting in one of the cars rolling free down the 33-degree incline before colliding with the other car. Five passengers received serious injuries, two passengers received minor injuries, and one passenger died as a result of his injuries. Additionally, debris from the collision fell and injured a nearby pedestrian. The accident was thoroughly investigated by the California Public Utilities Commission (CPUC or Commission) and the National Transportation Safety Board (NTSB). The funicular was taken out of revenue service at this time. One of the greatest concerns raised by the NTSB was that tests for metal particles in gear box oil were discontinued after an increased amount of metal in the oil was identified, in spite of a recommendation from the firm testing the oil to increase testing frequency because of the test results. The gear failure that resulted from the accelerated wear indicated by the oil tests was the primary cause of the accident. The NTSB concluded that if the testing had been increased and the results appropriately recognized, the accident could have been prevented. In January 2007, AFRC personnel met with CPUC staff (Staff) to communicate their intent to refurbish and re-open Angels Flight. AFRC contracted engineering and manufacturing services to refurbish Angels Flight. Angels Flight was once again reopened to the public in March 2010, with improved safety features that included a secondary safety cable, redundant fail-safe braking, and fail-safe carrier track brakes. The mechanical drive was once again redesigned, a state-of-the art controller was installed, and the entire system was refurbished in conformance with funicular standards (ANSI B77.2 – 2004) developed by the American National Standards Institute. Discussion Since the March 2010 reopening there have been three major maintenance and operational-related issues, including a derailment, which led to Staff directing AFRC to cease revenue service operations each time. The first major issue occurred on June 17, 2010, when Staff discovered that Angels Flight was being operated when the end gates were not closing. Staff immediately directed Angels Flight to cease service until the endgates were fixed and working as designed. The second major issue occurred on June 10, 2011, when Staff inspectors discovered excessive wheel flange wear during a routine inspection. Staff determined that continuing operations without providing mitigation was an unacceptable hazard that could lead to derailment, and directed AFRC to cease service.5 AFRC addressed the issue by replacing worn wheels, revising maintenance procedures to include detailed inspections of flange wear, and developing a condemnable flange wear limit that would specify when wheels needed replacement. AFRC was authorized to resume service operations by Staff on July 5, 2011. The third major issue was a derailment that occurred on September 5, 2013, in which a downward moving Angels Flight car derailed. Several contributing factors were identified as causes of the derailment, including improper operating practices that bypassed safety functions of the funicular system, inadvertent carrier brake activation, and carrier brake design issues. The NTSB determined: [The] probable cause of the September 5, 2013, accident was the intentional bypass of the funicular safety system with Angels Flight management knowledge; and Angel Flight management continuation of revenue operations despite prolonged, and repeated, unidentified system safety shutdowns. Angels Flight has been shut down since this derailment. This derailment was investigated jointly by Staff and NTSB personnel, who worked together with AFRC to develop a corrective action plan. Some individual components of the plan, as well as the number and critical nature of the tasks, define the work under the plan as “major projects” under the provisions of General Order 164-D. For example, the corrective action plan includes the redesign and installation of the carrier brake, start button reconfiguration, safety function reprogramming, fault logger reprogramming, replacement of wiring, operator training, better protection against passenger ejection, and construction of an evacuation walkway. We note that General Order 164-D requires a Safety Certification Plan (SCP) to be filed with the Commission when a project or projects of such magnitude are conducted, especially following an accident and a lengthy out-of-service period. General Order 164-D states: Each RTA [Rail Transit Agency] shall prepare a Project specific Safety Certification Plan (SC Plan) for each of its Projects. Applicable FTA [Federal Transit Administration] guidelines shall be used as a reference. Each RTA shall submit the SC Plan to Staff for review and Commission approval during the preliminary engineering phase. The RTA shall revise and expand the SC Plan as the Project progresses, as necessary. The RTA shall file any revision of the SC Plan with Staff. Within 45 calendar days, Staff shall approve or reject the proposed revisions. We affirm that due to the nature and extent of new and modified technical and operational systems proposed, the AFRC corrective action plan should have been formalized in an SCP, yet it was not. Though the redesign and installation of the carrier brake, start button reconfiguration, safety function reprogramming, fault logger reprogramming, replacement of wiring, and operator training have been completed and reviewed, there still are major projects that have not been completed, as described below. Accordingly, we direct that an SCP be filed with the Commission that includes all the items in the corrective action plan, the NTSB’s recommendations, and President Peevey’s directive. The two issues that remain open were in response to the 2001 collision and passenger fatality – lack of end-gates that would effectively prevent ejection, and lack of an adjacent evacuation walkway. In the 2001 collision, a passenger was ejected and suffered serious injuries.10 An effective endgate would have prevented his ejection, and likely would have minimized the extent of his injuries. Also, after the 2001 fatality, the NTSB concluded: The absence of an emergency walkway hampered access by emergency responders to passengers in this accident, made difficult the evacuation of the injured, and increased the risk to both passengers and emergency responders. [The] probable cause of [the February 1, 2001] accident was the improper design and construction of the Angels Flight funicular drive and the failure of various organizations involved in that design and construction to ensure that the railway system conformed to initial safety design specifications and known funicular safety standards. Regarding the lack of end-gates and an adjacent walkway, the NTSB found that in contrast to the original 1993 engineering plans, which included a formal risk analysis, that CRA/LA successfully persuaded the engineering firms to drop both features, in spite of warnings such as the following for the walkway: Under California Government Code Section 835, a public entity is liable for injury caused by a dangerous condition of its property if the dangerous condition was created by a negligent or wrongful act or omission and failed to take appropriate measures to protect against the dangerous condition… a successful effort by others to override the Public Utilities Commission and/or the Fire Department on the need for the emergency staircase… would place the Community Redevelopment Agency in jeopardy. After the reconstruction project was completed in March 2010, Staff authorized AFRC’s return to operation. Immediately after revenue operations commenced, however, the NTSB informed Staff that the NTSB recommendations had not been implemented as intended. Debate amongst the three organizations on how the recommendations should be implemented would continue due to differences in the interpretation of the ANSI B77.2 Funicular standards. The two safety issues that have not been completely resolved are the issues of passenger containment with effective end-gates, and emergency egress/ingress for passengers and emergency responders via an adjacent evacuation walkway. In letters dated May 18, 2010, December 29, 2010, and October 10, 2013, the NTSB clarified that its recommendations were for a track-adjacent emergency walkway with handrails and suitable structures that might be needed to get to the walkway (such as metal grating on the track-way) and for an end-gate at least 42 inches high or higher if deemed advisable by anthropometric design guidelines.15 This clarification was repeated in President Peevey’s November 8, 2013, letter to the NTSB Chairman. In a May 13, 2014, letter replying to President Peevey, the NTSB Acting Chairman responded in agreement. This resolution affirms our concurrence with the NTSB’s recommendations and President Peevey’s directives, and directs that the SCP must contain plans for constructing those safety enhancements, and be submitted for our approval. We ratify President Peevey’s November 8, 2013, letter. Additionally, because of the long and unsuccessful efforts to ensure that all NTSB recommendations are implemented, we require formal Commission approval of the Safety Certification Verification Report before Angels Flight is allowed to resume revenue service. Also because of the history of systemic safety problems, and the fact that the NTSB has opposed AFRC’s proposed alternatives, which could be deemed “workarounds” to the NTSB’s recommendations, and because the NTSB has approved the CPUC’s response without such alternatives or workarounds, we conclude that workarounds or open items will not be appropriate in this case. We will not allow any such workarounds or open items in our approval to resume passenger service, and instead require full implementation of all NTSB recommendations and CPUC directives. Notice On October 21, 2014, this Resolution was published on the Commission’s Daily Calendar. Comments The draft resolution of the Safety and Enforcement Division in this matter was mailed in accordance with Section 311 of the Public Utilities Code and Rule 14.2(c) of the Commission’s Rules of Practice and Procedure. Editorial corrections were received informally and are addressed in this resolution. No other comments were received. After the close of the comment period, Angels Flight transitioned to new management on December 10, 2014. As a courtesy to the new management, Staff held this resolution from the voting agenda to allow for meetings with the new management. On January 20, 2015, Staff met with Angels Flight’s new president, the new Chairman of the Board of Angels Flight, and a consulting engineer. At this meeting, the new Angels Flight President presented a new proposal for addressing the evacuation requirement. On February 5, 2015, Staff again met with Angels Flight personnel and consultants to gather information regarding proposed options for evacuation. It became clear during these meetings that there was a need for a listing of criteria for any evacuation structure, to ensure that proposed designs could be accepted. Staff has attached as Attachment C a compilation of NTSB recommendations and clarifications regarding an evacuation structure, as well as end-gates that would satisfy the NTSB specifications. Further clarification is provided in Attachment C by the correspondence between the NTSB and the CPUC that confirms what the NTSB accepts as meeting their recommendations. In summary, for the car end-gates, the NTSB recommendations specify: Entrance and exit gates 42 inches or higher based on an anthropometric-based design. For the evacuation structure, the NTSB recommendations specify:?Walkway adjacent to the trackway that would extend the entire length of the trackway. ?Track-level walkways with railings. ??Allows passengers to leave the stranded vehicles at any place along the guideway. ??Direct passenger egress along the guideway. ??Safe egress for passengers that self-evacuate without waiting for emergency response personnel. ??Addition of a structure to fill the gaps between ties to keep passengers from having to evacuate across open gaps. Therefore, IT IS ORDERED that: 1. The Angels Flight Railway Company shall file a Safety Certification Plan that adopts the recommendations of the National Transportation Board in its October 10, 2013, letter, and the directives of California Public Utilities Commission President Peevey in his November 8, 2013, letter. 2. This resolution ratifies California Public Utilities Commission President Peevey’s directives regarding the Angels Flight Railway Company in his November 8, 2013, to the National Transportation Safety Board, and the Angels Flight Railway Company shall implement those directives, without workarounds, as described in President Peevey’s letter, prior to resuming revenue service. 3. The Angels Flight Railway Company shall not resume revenue service operations without filing a Safety Certification Verification Report, which must receive formal approval from this Commission before service is resumed. This resolution is effective today. I certify that this resolution was adopted by the Public Utilities Commission at its regular meeting held on February 12, 2015. The following Commissioners voting favorably thereon: Michelle Cooke for Timothy Sullivan, Executive Director, Michael Picker, President, Catherine J.K. Sandoval, Carla J. Peterman, Liane M. Randolph, Commissioners.

From: NTSB
To: State of California, Public Utilities Commission
Date: 9/25/2014
Response: On May 13, 2014, we classified Safety Recommendation R 13 37 “Open?Acceptable Response” based on information you had provided in your November 8, 2013, letter. We also asked that you expedite action because this is an urgent recommendation. On August 27, 2014, Mr. John H. Welborne, President, Angels Flight Railway, provided the enclosed information regarding corrective measures that Angels Flight has taken related to Safety Recommendation R-13-37. Because Safety Recommendation R-13-37 was issued to the California Public Utilities Commission, the state regulating authority for such vehicles, we are forwarding Mr. Welborne’s information to you. Thank you for your continued efforts to address Safety Recommendation R-13-37.

From: NTSB
To: State of California, Public Utilities Commission
Date: 5/13/2014
Response: The series of corrective measures you described that will prevent excessive wheel and track wear, provide emergency stopping, ensure that safety systems are not bypassed, prevent passenger ejection, and provide a suitable means of emergency egress, when fully implemented, should satisfy Safety Recommendation R-13-37; accordingly, it is classified OPEN—ACCEPTABLE RESPONSE. Because this is an urgent recommendation, please expedite your actions.

From: State of California, Public Utilities Commission
Date: 11/8/2013
Response: -From Michael R. Peevey, President, California Public Utilities Commission: The California Public Utilities Commission appreciates the opportunity to work with the National Transportation Safety Board (NTSB) on the investigation of the derailment and subsequent passenger evacuation ofthe Angel's Flight Railway Company (AFRC) that occurred on September 5, 2013, in Los Angeles. As a result of this preliminary investigation, the NTSB developed five recommendations as described in the NTSB letter of October 10,2013. I describe the actions we will take to address each recommendation below. As you are aware, the Commission's Safety and Enforcement Division (SED) directed AFRC to cease service until all identified issues and concerns are corrected. Our staff (Staff) will discuss with the NTSB all proposed solutions and corrections of the recommendations. The CPUC will not allow AFRC to resume service until each recommendation has been adequately addressed. Recommendation 1: Preventing excessive wheel and track wear. Staff will investigate and discuss alternative wheel-axel assemblies and other wheel/track wear reducing measures with AFRC. One solution may be installing articulated axles on the vehicles. Staff will ensure that AFRC eliminates contact between the wheel flanges and rail fasteners before allowing any service resumption. Additionally, Staff will continue, as in the past, to regularly monitor wheel and rail wear. Recommendation 2: Providing emergency stopping under all foreseeable failure modes. AFRC indicates the existing spring-applied carrier brakes will be replaced by a new safety rope carrier brake. Staff will review the entire AFRC braking system. Staff will review the design of the rope carrier brake, inspect the subsequent installation, review the test procedure, and witness testing. Staff will ensure a reliable secondary braking system is in place. Recommendation 3: Ensuring safety systems are not bypassed. AFRC indicates it will replace the currently installed "start button" with a "required release switch" and also perform a complete system review to determine, and correct, the frequent unintended stops of the cars experienced prior to the derailment, which resulted in the bypass of existing safety systems. Staff will review and evaluate AFRC's assessment and corrective action plans for adequacy, and when Staff believes those plans are sufficient, will confirm that the appropriate actions are taken. Staff believes the System should be reprogramed so that any faults related to the braking system will shut down the vehicles from the main control room and that a Supervisor should be required to reset the entire system before the safety features will allow vehicles to operate. Staff will require that AFRC submit all of their Unusual Occurrence Logs to Staff each month so that Staff is aware of any hazards that AFRC may be experiencing. Staff will ensure that operational procedures are introduced that will prevent recurrence of a similar type of derailment, and that all AFRC operators are trained in these procedures. Recommendation 4: Preventing passenger ejection in the event of a collision. Staff will require that the exit gates at the end of each car be replaced with gates that are at least 42 inches in height or higher if deemed advisable by anthropometric design guides. Staff will assist and advise AFRC on the design of these gates as necessary. Recommendation 5: Emergency egress for passengers and ingress for emergency responders. Staff will ensure that AFRC improves emergency access. We understand from our previous correspondence that we and the NTSB apparently received different, albeit informal, interpretations of the standards for an "adjacent path" from ANSI. Through that correspondence we understand the NTSB' s recommendation is for a surface that passengers can access without ladders or concerns about traversing the cement ties. Even in the case that ANSI were to provide a formal interpretation consistent with the informal one we received, we will require implementation of means of egress and ingress consistent with the NTSB' s view. We understand this to be a track-level walkway with handrails and with suitable structures that might be needed to get to the walkway, such as metal grating on the track-way. We look forward to our continuing collaboration and to the satisfactory implementation of these recommendations.