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Safety Recommendation Details

Safety Recommendation R-09-007
Details
Synopsis: On Monday, June 22, 2009, about 4:58 p.m., eastern daylight time, southbound Metrorail train 112 was travelling in a curve when it struck the rear end of train 214 before reaching the Fort Totten station. Train 214 had stopped before entering the station to wait for another train to leave the platform. The striking train was not equipped with onboard event recorders that would have recorded train speed and other parameters. There was no communication between the train operators and the Metrorail Operations Control Center before the collision. During the collision, the lead car of train 112 telescoped and overrode the rear car of train 214 by about 50 feet. Examination of the track and wreckage indicated that the emergency brake on train 112 was applied before impact. The District of Columbia Fire and Emergency Medical Service reported 9 fatalities and transported about 52 persons to local hospitals. Although the NTSB’s investigation is ongoing and no determination of probable cause has been reached, investigators have concerns regarding the safety redundancy of WMATA’s train control system, which has prompted issuance of this urgent safety recommendation.
Recommendation: TO THE FEDERAL TRANSIT ADMINISTRATION: Advise all rail transit operators that have train control systems capable of monitoring train movements to determine whether their systems have adequate safety redundancy if losses in train detection occur. If a system is susceptible to single point failures, urge and verify that corrective action is taken to add redundancy by evaluating track occupancy data on a real-time basis to automatically generate alerts and speed restrictions to prevent train collisions. (Urgent)
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Railroad
Location: Washington, D.C., DC, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA09MR007
Accident Reports: Collision of Two Washington Metropolitan Area Transit Authority Metrorail Trains Near Fort Totten Station
Report #: RAR-10-02
Accident Date: 6/22/2009
Issue Date: 7/13/2009
Date Closed:
Addressee(s) and Addressee Status: FTA (Open - Unacceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FTA
Date: 4/26/2017
Response: In our July 23, 2014, letter, we noted that you had circulated a “Dear Colleague” letter to disseminate this recommendation to all rail transit operators and all state safety oversight (SSO) agencies. We further noted that your Transit Train Control Assessment quick study had been completed and was awaiting compilation. After reading your current submission, we acknowledge that the Transit Train Control Assessment is a thorough document that has identified the need to address train control system redundancies in case train detection losses occur. The stakeholders you met with while developing this assessment included Alstom and various transit agencies, and the final report addresses infrastructure needs, industry safety practices, and preventive maintenance needs, among other items, and includes recommendations to mitigate these concerns. Although the Transit Train Control Assessment final report is extensive, it appears that neither your safety office nor any SSOs have actually verified that rail transit operators have taken corrective action. Until you verify that all transit rail systems have implemented the recommended items in your assessment, and until that information is processed and we have reviewed it, Safety Recommendation R-09-7 remains classified OPEN--UNACCEPTABLE RESPONSE.

From: FTA
To: NTSB
Date: 2/23/2017
Response: -From Matthew J. Welbes, Executive Director: This recommendation arose from the NTSB's investigation of a June 22, 2009 accident, in which two heavy rail trains operated by the Washington Metropolitan Area Transit Authority collided with one another near the Fort Totten station. Nine people aboard train 112, including the train operator, were killed, and 52 people were injured. The accident caused $12 million in property damage. In the aforementioned letter to the FT A, you mentioned the posting to FT A's website of our "Dear Colleague" letter dated July 13, 2009, and other efforts undertaken by FTA to satisfy this urgent safety recommendation. Additional work included the quick study conducted by the Transit Cooperative Research Program, Project J-6 Task 77: American Public Transportation Association (APTA)/FTA Transit Train Control Assessment, for the FTA. I have enclosed the APTA/ FTA Transit Train Control Assessment final report. As a result of this report, APTA revised and strengthened their industry standard for audio frequency track circuit inspection and maintenance, APTA RT-SC-S-009-03 Rev 1, published on December 31, 2014. With the transmittal to the NTSB of the APT A/FT A Transit Train Control Assessment Final Report, we request the reclassification of Urgent Safety Recommendation, R-09-07 to Closed Acceptable Response.

From: NTSB
To: FTA
Date: 7/23/2014
Response: On July 9, 2010, we classified the recommendation “Open—Acceptable Response” because (1) you had circulated a “Dear Colleague” letter to disseminate the recommendation to all rail transit operators and all State Safety Oversight (SSO) agencies on the same day the recommendation was issued, (2) on the following day, you posted the letter on your website, and (3) as of April 28, 2010, the data for phase 2 of the Transit Cooperative Research Program’s Project J-6 Task 77, APTA/FTA Transit Train Control Assessment quick study, had been collected and was awaiting compilation. With the exception of the 2009 and 2013 Dear Colleague letters your staff provided, we have received no further information to date on your progress in implementing Safety Recommendation R-09-7, R-09-8, or R-09-9. Please provide us an update, preferably electronically at correspondence@ntsb.gov.

From: NTSB
To: FTA
Date: 7/9/2010
Response: The NTSB is pleased that, on the day that this urgent recommendation was issued, the FTA circulated a “Dear Colleague” letter to disseminate the recommendation to all rail transit operators and all State Safety Oversight (SSO) agencies and, on the following day, posted it on the FTA website. On April 28, 2010, Mr. Mike Flanigon, Director of Safety and Security, advised us that the data for phase 2 of the Transit Cooperative Research Program’s Project J-6 Task 77, APTA/FTA Transit Train Control Assessment “quick study,” has been collected and awaits compilation. Pending completion of the assessment, Safety Recommendation R-09-7 is classified OPEN -- ACCEPTABLE RESPONSE. The NTSB would appreciate receiving periodic updates as you continue actions to address Safety Recommendation R-09-7, as well as a copy of the Transit Train Control Assessment upon its completion. Thank you for your continued cooperation.

From: FTA
To: NTSB
Date: 2/16/2010
Response: Letter Mail Controlled 3/2/2010 1:48:22 PM MC# 2100073: - Pete Rogoff, Administrator: I have prepared this response to provide you with the current status of the Federal Transit Administration's (FTA) continuing activities to address Safety Recommendation R-09-7. I have also included an update on the Transit Cooperative Research Program (TCRP) consultant study, the minutes for the American Public Transportation Association (APTA) and other industry meetings, and the documentation of discussions with rail transit agencies. On July 13, 2009, I issued a Dear Colleague letter (enclosure 1) to the Rail Transit Agencies to advise them of this urgent recommendation. In addition to publicizing this recommendation at he jointly-sponsored FTA/U.S. Department of Homeland Security Safety and Security Roundtable in July 2009, FTA hosted the 13th Annual Rail Transit State Safety Oversight (SSO) Program Meeting in Tempe, Arizona in September 2009. The meeting was well attended by 88 representatives from rail transit agencies, State oversight agencies, FTA staff and other industry personnel. Bob Chipkevich, Jim Remines, and Steven Kleist from NTSB were invited and in attendance. Mr. Chipkevich made a presentation to the attendees and was able to give valuable insight and answer industry questions regarding NTSB recommendation R-09-7 as well as R-09-17, -18 and -19. Notes from that meeting are included (enclosure 2). On October 21, 2009, FTA issued a letter (enclosure 3) to the SSO Program Managers requesting their assistance in following up with rail transit agencies in their jurisdictions to confirm and monitor the actions being taken to address the issues identified by the NTSB recommendations. FTA continues to monitor the steps and actions that SSO Program Managers are taking in following up with these respective rail transit agencies. The TCRP quick study was initiated in August 2009. This effort resulted in a meeting in November 2009 with industry experts. The goal of this meeting was to develop industry consensus on the issues related to NTSB urgent safety recommendations. Notes from the meeting are included (enclosure 4). Ruben Payan from NTSB was invited and attended this two-day meeting. Mr. Payan’s participation was very helpful in clarifying the Board’s intent in issuing these recommendations. Moving forward, the TCRP quick study will enter its next phase, completing a signal system inventory for all North American rail transit systems. The initiative also will convene a technical working group, to evaluate best practices from the rail transit systems and to draft a Recommended Practice Document to provide the industry with information on detecting and preventing future occurrences of unsafe track circuit failure on rail transit systems. The final report is scheduled for completion in March 2010, and we will provide you a copy as soon as it is completed.

From: NTSB
To: FTA
Date: 12/30/2009
Response: The NTSB notes that, on July 13, 2009, hours after the urgent recommendation was issued, the FTA circulated a Dear Colleague letter to all rail transit operators to disseminate the information in the recommendation. State safety oversight agencies received copies of the letter, which was also posted on the FTA’s website the following day. The NTSB notes that, through the July 13 letter, the FTA seeks to determine how many rail transit agencies are capable of monitoring train movements and of determining whether their systems have adequate safety redundancy, should losses in train detection occur. The FTA urges transit agencies to take corrective action immediately to add redundancy to any systems susceptible to a single point failure by evaluating track occupancy data on a real-time basis and to automatically generate alerts and speed restrictions to prevent train collisions. The letter also indicates that the FTA will request transit agencies to provide information about specific train control systems and about compensating systems the agency may be able to develop should it determine that a single point failure could occur. NTSB staff contacted Mr. Michael Flanigon, Director, Office of Transit Safety and Security, who indicated that a consultant has been hired through the Transportation Research Board (TRB) to perform a quick study, inventorying rail transit systems to identify train control systems in use today and collecting data. The consultant will also identify redundant systems in place and monitoring technology currently available and will determine agency responses to Safety Recommendation R-09-7. Further, the consultant may inquire about an agency’s viable mitigation path toward positive train control systems. The study report will serve as a clearinghouse for information regarding best practices in addressing safety redundancy. The NTSB notes that the FTA has held discussions with the transit industry regarding Safety Recommendation R-09-7 at its Safety and Security Roundtable Meeting in Portland, Oregon, in July and continues to work with the American Public Transportation Association (APTA) to review APTA’s role in private consensus standard setting and in ensuring effective communication with the transit industry. The FTA has also been discussing Safety Recommendation R-09-7 with transit agencies to determine agency compliance. We look forward to reviewing documentation of the FTA’s efforts to satisfy Safety Recommendation R-09-7, including the TRB consultant study, APTA and other industry meeting minutes, and documentation of discussions with individual transit agencies. Pending a further update on FTA activities, Safety Recommendation R-09-7 is classified OPEN -- ACCEPTABLE RESPONSE.

From: FTA
To: NTSB
Date: 7/27/2009
Response: Letter Mail Controlled 8/5/2009 12:03:02 PM MC# 2090503: - From Peter M. Rogoff, Administrator: I am in receipt of your Urgent Recommendation (R-09-7) communication, dated July 13, 2009. derived from the National Transoortation Safetv Board's WTSB's), onr-roine- investigation of the recent collision between two Washington Metropolitan Area Transit Authority Metrorail trains, on the Red Line near the Fort Totten station in Washington, D.C. In response to the letter, we have taken the following immediate actions: The Federal Transit Administration (FTA) has advised all rail transit operators that may have train control systems capable of monitoring train movements to determine whether their systems have adequate safety redundancy if a loss in train detection occurs (Dear Colleague letkr, July 13,2009, enclosed). If a system is susceptible to single point failure, FTA urged that corrective action be taken to add redundancy, by evaluating track occupancy data on a real-time basis to automatically generate alerts and speed restrictions to prevent train collisions. For the purposes of verification, FTA will follow-up shortly with requests for information on specific train control systems and what compensating systems they have been able to develop if they have determined that a single point failure could occur. FTA has initiated discussions with the transit industry regarding NTSB's Urgent Recommendation R-09-7 at FTA's Safety and Security Roundtable Meeting, which took place this past week in Portland, Oregon. We will be working with the American Public Transportation Association to review their role in private consensus standard setting and to ensure effective communication with the transit industry. FTA has been having one-on-one conversations with transit agencies to gain insight as to how the agencies are complying with R-09-7.

From: FTA
To: NTSB
Date: 7/13/2009
Response: Letter Mail Controlled 7/23/2009 10:34:58 AM MC# 2090456: - From Peter Rogoff, Administrator: I write to you today to follow-up on an urgent recommendation the National Transportation Safety Board (NTSB) has made to the Federal Transit Administration (FTA) as the result of a preliminary analysis of the causes of the deadly Washington Metro Red Line heavy rail collision on June 22,2009. As you know, nine persons died and 70 persons were injured as the result of this two-train collision. The NTSB has determined, as a preliminary matter, that the Washington Metro train control system was susceptible to a single point failure. The system did not fail-safe and stop the train when train detection was lost. The NTSB has concluded that Washington Metro's train control lacked adequate safety redundancy that would have included timely alerts of system failures and compensation for intermittent failures or other anomalies in train detection. The NTSB has asked that we immediately issue an advisory to all transit rail operators around the country to address the potential safety vulnerability. Specifically, we are asking that all train operators that have train control svstems capable of monitoring train movements determine whether their systems have adequate safety redundancy if losses in train detection occur. If a system is susceptible to single point failure. We urge you take corrective action immediately to add redundancy by evaluating track occupancv data on a real-time basis to automatically generate alerts and speed restrictions to prevent train collisions. We at the FTA and the U.S. Department of Transportation hold safety as our number one priority. I request that you focus immediate attention on this important safety concern. For the purposes of verification, we will be following-up shortly with requests for information on specific train control systems and what compensating systems you have been able to develop if you have determined that a single point failure could occur.