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Safety Recommendation Details

Safety Recommendation R-16-007
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 FIRE AND EMERGENCY MEDICAL SERVICES DEPARTMENT: Implement measures to train all command officers who will serve in the role of incident commander in the skills and practices of National Incident Management System incident command and unified command processes. This training should include regular refresher 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, Fire and Emergency Medical Services Department (Open - Acceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: District of Columbia, Fire and Emergency Medical Services Department
Date: 5/3/2019
Response: We note that, at the time of the L’Enfant Plaza accident, your training requirements empahsized that incident commanders must understand how to implement the NIMS incident command and unified command processes, and you required NIMS incident command and unified command processes training for all members of the DC Fire and EMS Department. We further note that, in response to Safety Recommendation R-16-7, you reviewed your training requirements and discovered that knowledge and skills related to NIMS incident command and unified command processes were areas in need of improvement. We note that your existing NIMS training requirements were not actively managed and recorded, which created inconsistencies that contributed to noncompliance. Your review found that the NIMS incident command and unified command process training was not included in your minimum training and recertification standard, and records related to who had completed the training and who needed to complete it were poorly kept. Your letter informed us of the actions you have completed relating to this recommendation, including your April 2018 update to Bulletin 84, “Minimum Training and Recertification Standards,” and your implementation of an electronic system known as “Target Solutions” to replace your former, paper-based training records management system. We understand that, in January 2018, you loaded existing training records into the new electronic system and identified individuals in need of training or updated records. Since then, as of August 2018, 100 percent of your deputy chiefs, battalion chiefs, EMS battalion chiefs, and EMS lieutenants have completed the NIMS training, and between 63 percent and 97 percent of your captains, EMS captains, lieutenants, and sergenants have completed the NIMS training. In response to Safety Recommendation R-16-7, you have also taken steps to assure that command officers have the skills needed to implement the NIMS process. We note that you reviewed your existing policies and found that, in the past, officers were not given the opportunity to practice incident command at all stages of their career, which limited their ability to develop the skills necessary to perform as incident commanders; specifically, your standard operating guidelines (SOGs) did not conform to NIMS principles. To address this issue, in October 2017, you updated your SOGs, and during the first 3 months of 2018, all DC Fire and EMS Department employees received refresher training on the SOGs—specifically on the changes in the incident command structure. On March 19, 2018, you issued General Order 04 2018, which implemented these policy revisions. We are pleased that you have made the considerable improvements described in your Incident Command training. Pending 100 percent training of all of your 9 command officer positions to which this recommendation applies, Safety Recommendation R-16-7 is classified OPEN--ACCEPTABLE RESPONSE.

From: District of Columbia, Fire and Emergency Medical Services Department
To: NTSB
Date: 9/27/2018
Response: -From Gregory M. Dean Fire and EMS Chief: At the time of the January 12, 2016 incident, the Department's training requirements recognized and required the need for incident commanders to have the knowledge and skills to implement the National Incident Management Systems incident command and unified command processes by requiring NIMS ICS training for all members. Memorandum 148-2005: An Introduction to the National Incident Management System (NIMS) launched this policy. The Department's review of Recommendation R-16-7 identified two areas for improvement: knowledge and skills. KNOWLEDGE The recommendation seeks to ensure that all command officers understand the practices of the NIMS ICS System. We can ensure this by requiring incident commanders are appropriately trained in NIMS ICS processes. The Department's existing NIMS ICS training requirements were not actively managed and recorded, creating inconsistency. The following factors were identified as contributing to noncompliance: • NIMS ICS Training not included in Minimum Training and Recertification Standard • Poor Record Keeping NIMS ICS Training In April 2018, the Department updated Bulletin 84, Minimum Training and Recertification Standards, to incorporate the following requirements by rank: All Personnel NIMS ICS 700 Introduction to NIMS NIMS ICS 100 Introduction to the Incident Command System Sergeant NIMS ICS 200 - ICS for Single Resources and Initial Action Incidents NIMS ICS 800 - National Response Framework (NRF), an Introduction Fire Captain NIMS ICS 300 - Intermediate ICS for Expanding Incidents NIMS ICS 400-Advanced ICS EMS Battalion Supervisor (Captain) NIMS ICS 200 - ICS for Single Resources and Initial Action Incidents NIMS ICS 300 - Intermediate ICS for Expanding Incidents NIMS ICS 400 -Advanced ICS NIMS ICS 800 - National Response Framework (NRF), an Introduction Note: Progressive rank structures with the Department assure the ranks not listed have the certifications required of the ranks listed above. Specifically, Lieutenants will have the same NIMS requirements as a Sergeant and Chief Officers are expected to meet all training requirements. Record Keeping The paper based system used by the Department for Training Records was inadequate for the Department to ensure all members had been trained. The Department has undertaken a concerted effort to improve record keeping through the use of Target Solutions, a product the Department uses to support Emergency Medical Training and Recertification. In January 2018, the Department was able to load existing records into the systems and identify record keeping and training gaps. Using this information the Department has been able to identify individuals in need of training or updated records. As a result of identifying training gaps, the Department has been able to provide training to members who needed it, closing the NIMS ICS training and certification gap. (NOTE: NIMS I ICS Training is provided to members in multiple formats. NIMS ICS 700, NIMS ICS 100, NIMS ICS 200, and NIMS ICS 800 are offered through FEMA's online delivery. NIMS ICS 300 and NIMS ICS 400 are offered in a class room setting. In 2015 and 2016 in conjunction with the District of Columbia Homeland Security and Emergency Management Agency the Department delivered three sessions of NIMS ICS 300 and 400. The chart below shows the status of Department compliance with training in January 2018 and our current status in August 2018. Position # in Position Jan-18 Aug-18 Deputy Chief 12 83% 100% Position # in Position Jan-18 Aug-18 Battalion Chief 33 64% 100% Position # in Position Jan-18 Aug-18 EMS Battalion Chief 4 50% 100% Position # in Position Jan-18 Aug-18 Captain 67 64% 94% Position # in Position Jan-18 Aug-18 EMS Captain 42 12% 63% Position # in Position Jan-18 Aug-18 Lieutenant 178 83% 95% Position # in Position Jan-18 Aug-18 EMS Lieutenants 3 0% 100% Position # in Position Jan-18 Aug-18 Sergeant 124 94% 97% Position # in Position Jan-18 Aug-18 All Others 1261 60% 66% SKILLS The recommendation. also seeks to assure that command officers have the skills to implement NIMS ICS processes. A review of Departmental policy found that existing policies did not provide officers the opportunity to practice incident command at all stages of their career, limiting their ability to develop the skills necessary to perform as an incident commander. Specifically, the Department found: • Standard Operating Guidelines do not conform to the principles of National Incident Management System. Standard Operating Guidelines In 2016 the Operations Division began the process of updating the Department's Standard Operating Guidelines to conform to the principles of the National Incident Management System and update other operational practices. In October 2017, the Department published the updated the Fire and EMS Standard Operating Guidelines. In January 2018 the Department delivered an eight (8) hour Standard Operating Guidelines update to all Battalion Chiefs. In January, February and March of 2018 the Department delivered refresher training on the Standard Operating Guidelines and specifically the changes in the Incident Command Structure to all employees. On March 19, 2018 the Department implemented the policy change with General Order 04-2018; bringing the Department into compliance with NIMS principles for incident command. These changes to the SOGs and the refresher training are allowing officers and incident commanders to develop and practice the skills necessary to implement the incident command and unified command processes of NIMS ICS. Together the actions taken by the District of Columbia Fire and Emergency Medical Services Department to meet the requirements of the recommendation are substantial. The actions were implemented to improve business processes and change culture in order to ensure the Department is prepared and able to meet our mission of preserving life and promoting health and safety through excellent pre-hospital treatment and transportation, fire prevention, fire suppression, rescue activities, and homeland security awareness.

From: District of Columbia, Fire and Emergency Medical Services Department
To: NTSB
Date: 8/15/2018
Response: -From John A. Donnelly, Sr., Assistant Fire Chief, Professional Development Bureau, DC Fire and EMS: DC Fire and EMS is in the process of answering this request. I hope to have the answer to you within 30 days.

From: NTSB
To: District of Columbia, Fire and Emergency Medical Services Department
Date: 8/2/2018
Response: In the 2 years since this recommendation was issued, you have not sent us any information on actions that you have completed or are taking to satisfy it, and Safety Recommendation R-16-7 is currently classified OPEN--AWAIT RESPONSE. We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. We normally expect actions to address our recommendations to be completed within 3 to 5 years. Please update us at correspondence@ntsb.gov regarding your actions to address Safety Recommendation R-16-7, and do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: District of Columbia, Fire and Emergency Medical Services Department
Date: 5/23/2016
Response: On May 3, 2016, the National Transportation Safety Board (NTSB) adopted its report concerning the January 12, 2015,Washington Metropolitan Area Transit Authority (WMATA) L’Enfant Plaza station electrical arcing and smoke accident.1 Additional information about this accident and the resulting recommendations may be found in the report of the investigation, which can be accessed at our website, http://www.ntsb.gov,under report number RAR-16/01. As a result of this investigation, we issued 31new recommendations, including 2to the Federal Transit Administration, 1 to the mayor of the District of Columbia, 3to the District of Columbia Office of Unified Communications, 24 to WMATA, and the following recommendation to the District of Columbia Fire and Emergency Medical Services Department: R-16-07 Implement measures to train all command officers who will serve in the role of incident commander in the skills and practices of National Incident Management System incident command and unified command processes. This training should include regular refresher training. Chairman HART, Vice Chairman DINH-ZARR, and Members SUMWALT and WEENER concurred in this recommendation. The NTSB is vitally interested in this recommendation because it is designed to prevent accidents and save lives. We would appreciate receiving a response from you within 90days detailing the actions you have taken or intend to take to implement it. When replying, please refer to the safety recommendation by number. We encourage you to submit your response electronically to correspondence@ntsb.gov.