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Board Meeting: Railroad Accident Report - Collision of Two Washington Metropolitan Area Transit Authority Metrorail Trains Near Fort Totten Station, Washington, D.C., June 22, 2009 (DCA-09-MR-007) - Chairman's Opening and Closing Remarks
Deborah A. P. Hersman
National Transportation Safety Board (NTSB), Board Meeting: Railroad Accident Report - Collision of Two Washington Metropolitan Area Transit Authority Metrorail Trains Near Fort Totten Station, Washington, D.C., June 22, 2009, Washington, DC

Good Morning and welcome. I am Debbie Hersman and it is my privilege to serve as Chairman of the National Transportation Safety Board. This morning I am joined by my fellow Board members: Vice Chairman Chris Hart, Member Robert Sumwalt, Member Mark Rosekind, and Member Earl Weener.

This morning, the Board meets in open session as required by the Government in the Sunshine Act. While this is a public meeting, only the Board members and NTSB staff may participate in today's discussions. Three weeks ago, the staff presented to the Board the draft report we are considering today: the collision of two Metrorail trains on the Red Line near the Fort Totten station on June 22, 2009.

While the individual Board members have had the opportunity to read the accident report and to meet with the staff individually, today is the first time that all five Board members are meeting together to discuss it. Staff has prepared five presentations, which will be followed by a round of questions from the Board members. We will then consider the report's conclusions, probable cause determination, and proposed safety recommendations.

Just over one year ago, on a warm summer afternoon as that day's evening commute was getting underway here in Washington, D.C., tragedy struck on the Red Line near the Fort Totten station. Two trains collided, killing nine people aboard train 112, including the operator, and injuring 52 people.

Within minutes of the crash, the National Transportation Safety Board was on the scene, beginning our year-long investigation into the circumstances that caused it.

I was among the Safety Board personnel who responded to the scene that day. Then, and in the days and months since, I have had the opportunity to meet many of the family members of the victims, as well as those who sustained injuries. I know I speak for the entire Safety Board when I say that our thoughts remain with them. Many of the family members and those injured in the crash are in the Board room today or watching via webcast. Nothing can replace the loss of a loved one or repair the trauma of a life-changing injury. But we do have the opportunity - and the obligation - to take every step possible to ensure that the lessons of this tragedy are well-learned, and that the circumstances are never repeated.

Over the course of the last year, this accident investigation has been a major focus of our staff and resources, particularly for our Office of Railroad, Pipeline and Hazardous Materials Investigations, and our Office of Research and Engineering. On behalf of the Board, I want to thank the staff for its thorough investigation and hard work. Although I was the Member on scene, I was only there for the first days following the accident. Our staff spent an unprecedented six weeks on site, investigating every clue and piece of evidence to discover what went wrong.

In addition, we conducted a three-day public hearing this past February, which was chaired by Member Sumwalt. That public hearing provided significant additional information that has helped to form the many conclusions and recommendations of this report. At Member Sumwalt's urging, many important issues regarding WMATA's safety culture were addressed during the hearing, and I thank him for his leadership in that area.

Much of today's meeting will focus on the design and operation of Metro's track circuits - electrical equipment that provides the basic information to the automatic train control system that is the heart of Metrorail operations. We will discuss train control modules, impedance bonds, and parasitic oscillation. The story of the track circuit failure is a complicated one. Essentially, the track circuitry failed - it stopped detecting the presence of a train that was approaching the Fort Totten station, causing that train to stop short of the station. Consequently, the control system transmitted speed commands to the following train -essentially telling the following train that the track was clear ahead, when in fact it was not. It was only when the train came through a blind curve that its operator saw the stopped train ahead - but it was too late.

In a larger sense, the Safety Board's investigation revealed much more than the failure of a track circuit. The layers of safety deficiencies uncovered during the course of this investigation are troubling and reveal a systemic breakdown of safety management at all levels.

Metro was on a collision course long before this accident. As our report shows, this was not the first time Metro's safety system was compromised. Past accidents like Shady Grove and Woodley Park, as well as Eisenhower Avenue, Dupont Circle, and Mount Vernon Square which resulted in employee fatalities, and a 2005 incident under the Potomac River near Rosslyn Station, have served as a prologue to the tragedy at Fort Totten. Because the necessary preventive measures were not taken, the only question was when would Metro have another accident - and of what magnitude.

The Safety Board has a dual responsibility - both to look back at the causes and failures of an accident, and to look forward. When we shift our view forward, we hope that the leadership and the workforce at WMATA will see the signals of a new day.

You are going to hear a lot about WMATA's anemic safety culture today. I think everyone can agree that WMATA has serious challenges ahead. Implementing an organization-wide culture of safety won't happen overnight. It must be top to bottom, incorporating everyone from the Board to senior management, to the train operators and the safety inspectors, to the line operators and administrative employees. When safety is more important than schedules, their organizational culture can be a success. Our hope is that the lessons learned from this accident will be not only a catalyst for change at WMATA, but also the cornerstone of a greater effort to establish a federal role in oversight and safety standards for rail transit systems across the nation.

There is no more valuable currency to a transit system than the trust of its ridership. The accident at Fort Totten severely shook the faith of Washington area riders and the millions of tourists who visit this city. WMATA can win back that trust by taking our safety recommendations to heart, and, at its core, fundamentally changing its culture. This effort has begun, but there is still a long ride ahead.