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Safety Recommendation Details

Safety Recommendation R-16-006
Details
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: Train call takers for the public service answering point on the standards developed in Safety Recommendation R-16-05, and include the standards in recurrent training.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Railroad
Location: Washington, DC, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: 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)
Keyword(s):

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
To: NTSB
Date: 8/17/2016
Response: -From Karima Holmes, Director: Since its inception, the Office of Unified Communications (OUC) has engaged in regular training of its call takers and dispatchers on call processing standards. In fact, OUC initiated the process of certifying its emergency personnel in the various protocols beginning in 2006, when the first group was certified by the National Academies of Emergency Dispatch (NAED) in Emergency Medical Dispatcl1 (EMD) protocols. NAED has its origins in the National Academy of Emergency Medical Dispatch that was created in 1988 as a standard-setting organization for the field of emergency medical dispatch. Fire and Police Academies and protocols were later added, making NAED the industry leader for multi-agency dispatching that was based on research, testing, and quality assurance. The EMD protocol certification meets or exceeds all national criteria set by the American Society for Testing and Materials (ASTM), the U.S. Department of Transportation, the National Association of EMS Physicians, and others. Initial certification requires completion of a three-day course, the passing of a 50-question certification exam with a score of at least 80%, and CPR certification through the National Safety Council, American Heart Association, American Red Cross, European Resuscitation Council, or equivalent. NAED certification must be renewed every two years and requires passing an exam with a score of 80 or above and the completion of at least 24 hours of Continuing Development Education (CDE). OUC subsequently expanded the scope of required certifications and engaged in recertification as follows: EMD 91 6 118 6 109 15 93 54 76 95 22 EMD-Q 3 0 0 5 0 0 0 0 0 27 5 EFD 0 0 2 200 25 172 6 139 15 139 27 EFD-Q 0 0 0 16 0 0 0 0 0 5 4 EPD 0 0 2 197 20 186 8 164 11 160 13 EPD-Q 14 0 0 0 0 0 7 7 ETC 0 0 0 0 0 0 0 0 438 154 373 107 357 102 433 78 2164 EMD EMD-Q 3 5 26 5 EFD 0 2 200 25 4 39 11 47 13 EFD-Q 0 16 5 4 EPD 0 2 197 20 9 20 5 43 6 EPD-Q 0 7 7 ETC 0 94 6 36 432 73 19 0 107 30 191 38 926 EMD EMD-Q 0 EFD 0 168 6 100 4 92 14 EFD-Q 0 EPD 0 177 8 144 6 117 7 EPD-Q 0 ETC 0 0 0 86 6 81 354 107 250 72 242 40 1238 Emergency Fire Dispatch (EFD) protocol certification training combines the latest technology in systematic call interrogation with the ability to logically prioritize dispatch responses and give lifesaving pre-arrival instructions immediately to the caller at the scene, saving precious time while first responders arrive. The protocol has been designed to protect against liability while increasing call processing effectiveness and assuring measurable standards of equalized care to the public. Emergency Police Dispatch (EPD) protocol certification training was created to effectively deliver the best possible level of public care while protecting dispatchers and their centers from liability. The 35 Chief Complaint Protocols cover most if not all of the possible scenarios encountered in law enforcement call centers and provide a measurable and equalized standard of law enforcement practice for the public for each call taken. EMD-Q, EFD-Q, and EPD-Q certification training is designed for dispatch supervisors, quality assurance/quality improvement personnel, and is part of an overall quality management process to significantly improve PSAP operational performance. More recently, OUC 9-1-1 call takers have begun to receive certification through the Association of Public Safety Communications Officials (APCO), an organization that serves the needs of public safety communications practitioners worldwide - and the welfare of the general public as a whole - by providing complete expertise, professional development, technical assistance, advocacy and outreach. APCO's Public Safety Telecommunicator (PST) certification training covers the basics skills, knowledge, and abilities every successful 9-1-1 call taker needs to meet the demands of this critical work. The basic PST Training Course meets or exceeds the American National Standards as contained in the ANSI approved Minimum Training Standard for Public Safety Telecommunicators (APCO ANS 3.103.2.2015). Building on foundational topics such as communication skills, calltaking and radio techniques, the PST course incorporates the most up-to-date information on technology and work-related issues in PSAPs. Topics include Next Generation 9-1-1 , emerging technologies, continuing education and liability. OUC also recently developed the Certified Training Officer (CTO) position to provide mentoring and direct training to new emergency employees. CTOs undergo the Communications Training Officer certification course provided by APCO. The CTO training program focuses on the development and maintenance of an agency's one-on-one training program and provides the training necessary to foster levels of consistency for CTOs as they provide on-the-job training to new hires. The history of PST and CTO certifications of OUC employees through APCO is as follows: COURSETITU COURSE START END CERTIFIED TOTAL CERTIFIED REGISTRANTS TYPE DATE DATE REGISTRANTS (PER YEAR) Public SafetyTelecommunlcator 16th. ~37503 Contract 3/9/2014 3/13/2014 14 Public Safety TeleCommunicator 16th, #37502 Contract 3/9/2014 3/13/2014 12 Public Safety TeleCommunicator 1 6th, ~3750<1 Contract 3/16/2014 3/20/2014 14 Public Safety Telecommunicator 16th, #37505 Contract 3/16/2014 3/20/2014 11 - Public Safety Telt>Communicator 1 6th, #37507 Contract 3/23/2014 3/27/2014 l3 Z0.1.4£PSfl Public Safety Telttommunicator 16th, N37506 Contract 3/B/2014 3/27/2014 13 l'i4 Public Safety Telecommunicator 16th, #37508 Contract 3/30/2014 4/3/2014 11 - Pubfic Safety Telttommunicator 16th, 07509 Contract 3/30/2014 4/3/2014 12 Z0.1.5(PSfl Public SafetyTelecommunicator 16th, #37510 Contract 4/21/2014 4/24/2014 16 <;7 Public Safety Tclecommunicator 16th, 437511 Contract 4/21/2014 4/24/2014 12 - Public Safety Telecommunicator 16th, #37513 Contract 4/27/2014 5/1/2014 11 Z01.5(CTOl PubliC Safety Telecommunicator 16th. R37512 Contract 4/27/2014 S/1/2014 l5 l9 Public Safety Telecommunicator 16th, ~39812 Contract 2/9/2015 2/13/1015 21 1- Public Safety Telecommunicator 16th. #39814 Contract 2/23/2015 2/27/2015 12 2016(PSTl Public Safety Telecommunitator 16th, 139813 Co-Hosted 2/23/2015 2/27/20l5 10 1~ Public Safety Telecommunicator 16th. il415ll Contract 9/21/20l5 9/25/2015 14 Public Safety Telecommunicator 17th, #442ll Contract 7/11/2016 7/15/ID16 19 Communk.ations Training Officer 5th, #40258 Contract 3/19/20l5 3/21/20l5 11 Communications Training Officer 5th, #40360 Contract 4/8/2015 4/10/2015 8 Finally, the D.C. Council is currently considering legislation that will codify the training requirements for OUC emergency personnel. The Office of Unified Communications Training, CPR. and Modernization Amendment Act of 2015 (Act) was introduced on June 30, 2105 (attached). As introduced, the Act requires that OUC provide training for all employees and establishes a required amount of minimum hours for annual training and certification for the position of public safety communications training officer and public safety telecornrnunicator, in accordance with standards established by a national public safety association. The Act includes a requirement to offer an annual exam for public safety communicators as well as the establishment of an annually published training schedule. In conclusion, OUC has a long-standing record of establishing call processing standards based on national standards, training its emergency personnel on those call processing standards, and annually auditing the agency's performance in relation to call processing standards. OUC is committed to providing fast, professional, and cost effective response to emergency and non-emergency calls in the District.