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Safety Recommendation Details

Safety Recommendation R-16-021
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 WASHINGTON METROPOLITAN AREA TRANSIT AUTHORITY: Revise Standard Operating Procedure #6 to clarify which trains should be stopped until the source of smoke is identified.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
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: 11/15/2018
Addressee(s) and Addressee Status: Washington Metropolitan Area Transit Authority (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Washington Metropolitan Area Transit Authority
Date: 11/15/2018
Response: We are pleased that you have updated your Metrorail Safety Rules and Procedures Handbook (MSRHP) to emphasize Standard Operating Procedure #6 for fire- and life-safety processes in underground and aboveground stations and in tunnels. We note that the formal report reviews existing operations and evaluates emergency rail operations procedures, as well as details procedure revisions. Further, you have also developed an employee training program that includes direct employee training and additional training recommendations. The formal report you sent us is extensive and clarifies that the rail operations supervisor should investigate fire and smoke occurrences, and that all revenue trains with passengers onboard must stop and not enter a smoky environment. Finally, we note that, in the event of smoke or fire, your standard operating procedure makes the Metro Transit Police Department and the chiefs of the District of Columbia Fire and Emergency Medical Services Department lead of operations. We believe that the program you have described will result in a safer experience for your passengers and will enhance employee performance. Accordingly, Safety Recommendation R 16 21 is classified CLOSED--ACCEPTABLE ACTION. Thank you for taking these actions to improve rail safety.

From: Washington Metropolitan Area Transit Authority
To: NTSB
Date: 7/6/2018
Response: -From Angel Pena, Managing Director, Quality Assurance, Internal Compliance and Oversight (QICO), WMATA: This is a letter to request closure of Safety Recommendation NTSB R-16-21 from May 23, 2016. The recommendation stated, “Revise Standard Operating Procedure #6 to clarify which trains should be stopped until the source of smoke is identified.” WMATA is providing the attached documentation of completed actionable items addressing the safety recommendation, as described in Corrective Action Plan R-16-21. Completion of actionable items demonstrates our organizational commitment to improving the safety and reliability of the Metrorail system, our riders and employees. Please see the attached actionable items and contact me for any additional information or clarification.

From: Washington Metropolitan Area Transit Authority
To: NTSB
Date: 6/30/2017
Response: -From Angel Pena, Managing Director, Quality Assurance, Internal Compliance and Oversight (QICO), WMATA: After a collective review of the Washington Metropolitan Area Transit Authority (WMATA) Corrective Action Plans (CAPs) submitted to the National Transportation Safety Board (NTSB) on August 18, 2016, the attached documentation is provided to support the closure of Safety Recommendation NTSB R-16-21: Ensure that all train operators are trained and regularly tested on the appropriate procedure for emergency shutdown of railcar ventilation. WMATA is providing documentation of completed actionable items addressing the safety recommendation, as described in CAP R-16-21, submitted to the NTSB on August 18, 2016. Completion of actionable items demonstrates our organizational commitment to improving the safety and reliability of the Metrorail system, our riders and employees. Please see the attached actionable items and contact me for any additional information or clarification.

From: Washington Metropolitan Area Transit Authority
To: NTSB
Date: 8/18/2016
Response: -From Patrick Lavin, Chief Safety Officer: WMATA is in the process of reviewing the Metrorail Safety Rules and Procedures Handbook (MSRPH) for revisions and updates, which contains Standard Operating Procedure (SOP) #6. In the process of updating the MSRPH, WMATA will include revisions to SOP #6 to explicitly identify all trains that should be stopped in a smoke incident until the source of smoke is identified. This will include direction for stations containing multiple rail lines or multiple platform levels to specify what should occur on each line and track. (Estimated Completion: 12/01/16 – See attached CAP: NTSB R-16-21)

From: NTSB
To: Washington Metropolitan Area Transit Authority
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 2 to the Federal Transit Administration, 1to the mayor of the District of Columbia, 3to the District of Columbia Office of Unified Communications, 1 to the District of Columbia Fire and Emergency Medical Services Department, and the following 24 recommendations to the Washington Metropolitan Area Transit Authority. (List of Safety Recommendations). Chairman HART, Vice Chairman DINH-ZARR, and Members SUMWALT and WEENER concurred in these recommendations. The NTSB is vitally interested in these recommendations because they are 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 them. When replying, please refer to the safety recommendations by number. We encourage you to submit your response electronically to correspondence@ntsb.gov.