NTSB - Greater Greater Washington

Silver Line extension explained

Thu, 06 Dec 2012 08:26:00 EDT

The pocket track near Stadium-Armory can't fit NTSB-recommended switches to prevent derailments and is too short for 8-car trains to turn around quickly. Therefore, Metro will send Silver Line trains to Largo. (Post)

Comment

A major NTSB safety recommendation remains forgotten

Thu, 05 Jul 2012 16:16:00 EDT

by Ben Ross

After the fatal Metro crash at Fort Totten, state, local, and federal agencies all agreed that Metro must comply with the recommendations of the National Transportation Safety Board at all cost. Metro is now spending well over a billion dollars to satisfy NTSB point by point.

Photo by bjosefowicz on Flickr.

Yet our region's transportation system is ignoring one NTSB recommendation—even though it would cost no money while saving more lives than any of the ongoing rail safety upgrades.

Last December, the federal agency recommended a complete ban on the use of portable electronic devices such as cell phones (hand-held and no-hands alike) while driving. Yet none of the jurisdictions in the WMATA compact area has taken any action to comply.

While the safety problems on Metrorail that came to light at Metro after the 2009 crash are very real, by far the most dangerous part of a Metro rider's journey is the walk to the station or bus stop. A total of 854 pedestrians were killed by drivers of motor vehicles in the Washington area between 2001 and 2009.

There are no statistics on how many of the 854 pedestrian deaths cellphone use contributed to, but anyone who watches drivers at busy intersections knows that it has to be a significant fraction. For Metrorail, the eight passengers who died in the Fort Totten accident were the only fatalities in this period.

Implementing this NTSB recommendation is mainly up to the two state legislatures and the DC Council. But Metro itself can lead the way. Under Article 76(e) of the WMATA compact, Metro's board can adopt regulations for traffic on Metro's facilities. Metro should act on its own to ban cellphone use by drivers of moving vehicles in garages, kiss-and-rides and other Metro property.

Drivers will be inconvenienced if they must stop their cars to use a cellphone. But weekend service interruptions caused by safety upgrades are already a major hassle for Metro riders. Local governments have decided that is a price that has to be paid for passenger safety. If inconvenience to transit riders is no reason to ignore the NTSB, neither is inconvenience to drivers.

33 comments

NTSB blames track circuits, safety culture for Red Line crash (Jul 27, 2010)
Recommendation to replace 1000 series wasn't ignored (Jul 28, 2010)
Senators threaten WMATA takeover; NTSB holding hearing on June crash (Feb 23, 2010)
Time to reaassemble railcars into single-series trains (Mar 15, 2010)
How has Metro responded to NTSB recommendations? (Oct 22, 2009)

Safety on the rise

Fri, 22 Jun 2012 08:28:00 EDT

by Steven Yates

Three years after the Fort Totten crash, outside groups like the NTSB and Tri-State Oversite Committee think Metro is safer now but several smaller incidents indicate that there is still much work to be done. (Post)

Comment

NTSB calls for cellphone ban

Thu, 15 Dec 2011 08:13:00 EDT

by Steven Yates

The National Transportation Safety Board recommended a complete ban on cellphone use while driving, including hands-free devices. They know it'd be unpopular, but say it's needed for safety. (NY Times, Ben Ross)

Comment

NTSB blames track circuits, safety culture for Red Line crash (Jul 27, 2010)
Senators threaten WMATA takeover; NTSB holding hearing on June crash (Feb 23, 2010)
Should NTSB recommendations get a blank check? (Sep 30, 2010)
WMATA Board not at fault for crash, but needs to step up (Jul 27, 2010)
Metro safety presentation still doesn't prioritize (Oct 27, 2010)

NTSB report questions 1000 series

Wed, 13 Apr 2011 08:58:00 EDT

by Erik Weber

The NTSB report on the November 2009 rail yard crash again questions the crash worthiness of 1000 series cars which were totalled in the crash despite traveling at most 19 mph. (Examiner)

Comment

Recommendation to replace 1000 series wasn't ignored (Jul 28, 2010)
Time to reaassemble railcars into single-series trains (Mar 15, 2010)
NTSB blames track circuits, safety culture for Red Line crash (Jul 27, 2010)
Are Metro's 1000 Series cars safe? Can Metro do anything about it? (Jun 25, 2009)
Senators threaten WMATA takeover; NTSB holding hearing on June crash (Feb 23, 2010)

Might Sarles stay?

Mon, 17 Jan 2011 09:35:00 EDT

by David Alpert

Richard Sarles might not mind staying on the job, and gets praise from Board members. He has improved WMATA's relationship with the NTSB, though mostly by uncritically doing whatever they say rather than prioritizing hazards and also says he is set on continuing the bag searches simply because other cities are doing it. (Post)

Comment

Metro workers afraid to report hazards, Board unfazed (Oct 12, 2010)
Bag search policy another example of siloed thinking (Jan 6, 2011)
Richard Sarles will make safety top priority, ride Metro (Mar 4, 2010)
WMATA Board not at fault for crash, but needs to step up (Jul 27, 2010)
Sarles focusing on "basics" of safety, reliability, finances (May 11, 2010)

Should the FTA regulate urban transit agencies?

Fri, 29 Oct 2010 11:30:00 EDT

by Ken Archer

Imagine if Metro had to pay a fine for every safety standard violation. What if Metro officials and operators lost licenses to work in transit if they repeatedly violated safety standards?

Photo by atomicfamily on Flickr.

These ideas could become reality if the FTA gains the ability to regulate public transit agencies. And while many Washingtonians regard this as a no-brainer, there are serious concerns that few are considering in the post-Red Line Crash fear-mongering.

The standard argument in favor of FTA regulation is that regional safety oversight bodies are simply too unprepared and ill-equipped to assure safety on America's transit systems.

These bodies, like the Tri-State Oversight Committee which provides safety oversight of Metro, have little to no staff and no enforcement powers. The DOT oversees safety on Amtrak, so why not subway and light-rail systems too?

While this standard argument is compelling, there has been little engagement with the counterargument to federal oversight of urban transit. Consider the following concerns.

Urban rail is very safe: Subways and light rail are already very safe, safer by far than other modes of transportation that are regulated by the DOT including air travel. One wonders then if improving on an already very low fatality rate should be a priority for federal dollars given the other more dangerous modes regulated by the DOT.

The TOC can be improved easily without federal intervention: The criticism leveled against the TOC is not directed at their competence, but at their lack of enforcement powers and funding. So, instead of building a new federal agency, why not give the TOC enforcement powers and increased funding?

TOC audit was actually better than the FTA audit of Metro: While it received little press attention, the TOC audit released earlier this month was more detailed and actionable than either the NTSB or FTA audits concerning the systemic safety hazards at Metro.

Federal urban rail regulation may be unconstitutional: Federal regulation of urban transit systems may ultimately be overturned by the courts. The Commerce Clause of the Constitution limits federal regulation to interstate commerce, and most urban transit systems don't cross state lines like Metro does.

NTSB previously opposed FTA oversight of urban rail: Every urban transit system is very different, despite appearances to the contrary. Unlike other transit modes regulated by DOT which share a common network, urban transit systems develop independently according to unique needs and constraints. The NTSB argued in the 90s that this was reason enough to support the regional system of safety oversight in place today.

For these reasons, I would strongly oppose FTA regulation of Metro and other urban transit agencies if not for one prominent benefit that would result from FTA regulation:

FTA can balance NTSB: While the NTSB serves a valuable role in transportation safety, they are an exclusively reactive organization by statute. Unfortunately, the political pressure to implement any and all NTSB recommendations is overwhelming. This undermines attempts to create a proactive safety organization.

The USDOT, which requires transportation providers to take a more proactive approach to safety, balances the NTSB in the transport modes that it regulates. This balance will never be provided by the TOC or other regional safety oversight bodies.

I am honestly on the fence on this critical issue. While the answer to this issue seems obvious to many, I suspect that the damning of all things Metro since the Red Line Crash is undermining the healthy debate that this issue deserves.

The Obama administration supports a bill that would give the FTA this power, but Senator Tom Coburn (R-OK) has put a hold on the bill in the Senate for many of the reasons listed here, as well as the lack of offsetting spending cuts or taxes in the legislation.

What do you think? Should the FTA regulate urban transit agencies?

13 comments

Senators threaten WMATA takeover; NTSB holding hearing on June crash (Feb 23, 2010)
Can oversight help transit safety without hurting transit? (Nov 16, 2009)
Metro workers afraid to report hazards, Board unfazed (Oct 12, 2010)
Next stop: Metro funding (Aug 3, 2009)
WMATA Board not at fault for crash, but needs to step up (Jul 27, 2010)

Metro safety presentation still doesn't prioritize

Wed, 27 Oct 2010 10:56:00 EDT

by Michael Perkins

WMATA will hold its first meeting of the new Safety and Security Committee tomorrow, split off from the previous Customer Service, Operations and Safety Committee. The staff presentation still needs more information to help the board oversee safety, including a sense of priorities.

Photo by the|G|™ on Flickr.

The presentation lists the status of NTSB recommendations and the cost to complete each. That is helpful, but doesn't provide any information about what vulnerabilities each recommendation fixes, and what criteria the staff used to prioritize.

The recommended fixes range from the relatively inexpensive ($350,000 for "Improve Internal Communications") to the cost-prohibitive ($835M for "Removal of 1000 Series Rail Cars").

Metro also provides information about the operating divisions that have the most days without a lost time injury, highlighting their best performance. It is a good idea to commend those divisions for maintaining safe work practices and keeping their workers safe. But for a board oversight role, it would be more instructive to show the operating divisions with the worst safety record, and show what are the findings from safety assessments or the results of incident investigations into the injuries.

Metro should look at their best performing divisions as a source of best practices to transfer over to other divisions where workers have been injured. Rather than highlight their best performance, Metro and its oversight board should be looking into their worst performance in order to improve it.

In my opinion, the least valuable part of this presentation is a series of 10 bar charts showing the number of various types of incidents in 2009 compared to 2010. Metro shows that the "2009 Average" rail passenger injury rate was 0.47 per million passenger trips, and that the 2010 injury rate to date is much lower, at 0.14.

This allows the casual reader to think that Metro is somehow improving. But the previous year had the worst accident in Metrorail history, and should not be used as a sort of "average." Instead, Metro should treat every accident as undesirable, and avoid showing averages unless they are based on the long-term average rate over the past decade or a similar time period.

Given these charts showing incident and injury rates varying over 16 months in the past, what is the board supposed to do? There isn't any analysis given, only data. Are a lot of the injuries preventable? Are they related to the NTSB findings and therefore the money to be spent on fixes would help the incidents Metro is experiencing? Is there some other fix that would help to prevent these incidents?

Metro is showing data about the injury rate, but there is no explanation about why the rates are increasing or decreasing. Maybe this will be part of the discussion, but so far it doesn't look like Metro has dug into what the problems really are.

Compare this with the discussion about Elevator and Escalator repair. Metro had to call in an assessment consultant to find its problems, and plans to re-hire the same consultant to figure out whether the corrections have stuck. This indicates that at least in some areas, Metro has lost the ability to assess its own performance, and must rely on outside organizations like consultants, the NTSB and the TOC to find its problems and recommend fixes. One of Metro's goals should be to develop a culture of self-assessment, so that the organization can better find problems itself without relying on outside help.

5 comments

Senators threaten WMATA takeover; NTSB holding hearing on June crash (Feb 23, 2010)
The Price of Safety (Sep 29, 2009)
The Price of Safety, part 1: Track workers face danger (Oct 2, 2009)
NTSB blames track circuits, safety culture for Red Line crash (Jul 27, 2010)
Metro audit portrays isolated safety management (Oct 18, 2010)

Metro workers afraid to report hazards, Board unfazed

Tue, 12 Oct 2010 14:11:00 EDT

by Ken Archer

Some 30% of Metro employees don't report safety hazards for fear of retaliation. That's according to testimony from Metro General Manager Sarles at the most recent Metro Board meeting, which included the results of an employee survey of Metro's safety culture.

Metro Board Chair Peter Benjamin.

If that isn't alarming enough, the response of the Chair of the Metro Board will be. Board Chair Peter Benjamin effectively blamed the workers for their perceptions.

According to General Manager Sarles:

Approximately 60% of those surveyed said that they have observed a safety-concerned violation in the past year while on the job at Metro. This is concerning. But we also learned that of those observing concerns, approximately 70% are reporting their concerns with their first reporting channel being their supervisor.

That means that 42% of workers (70% of 60%) have reported a safety hazard in the past year. That's alot of safety hazards reported. That also means that 30% of safety hazards noticed by workers aren't being reported. Sarles then addresses the latter issue of fear of retaliation.

There is a strong concern about retaliation but in somewhat unexpected ways. Employees' primary concerns are not that they would be fired or demoted. The strongest concerns that were cited were that it would be difficult for them to work among their peers, that the organization wouldn't do anything about their report, and that the organization would not protect them against retaliation in their immediate working environment.

So, imagine that you are the Chair of the Board at this point. The NTSB has excoriated your Board for its lack of safety oversight following the Red Line crash that killed 9 people. Everyone is pushing Congress to let the FTA regulate transit agencies because of your Board's failure in oversight.

You have responded to the NTSB and FTA by saying that you are now up to the task of safety oversight, and are modifying your mission statement in the very same meeting to place more focus on safety.

You would probably ask if the workers are correct that the organization wouldn't do anything about their report. What does the organization do with reports of safety hazards, and is this process documented and audited? What has it done with the safety hazards reported by 42% of workers?

Board Chair Benjamin:

My reaction is that your report is impressive, it's thorough, it's in-depth, it's exhaustive, and more than anything else it shows your leadership as a General Manager, and the combined efforts of a really dedicated senior staff, middle management and staff throughout this authority. It's an extremely, extremely good report.

Huhh? What is "extremely, extremely good" about 60% of workers noticing safety hazards and 30% of workers fearing retaliation if they report safety hazards?

I would like to comment very briefly on the employee survey because it's such an interesting set of results which reflect not necessarily reality but perception. And in this particular case, perception is so important. Because if what you are trying to do is revamp your culture, you have to know where you're starting.

So, after lauding praise on management, Benjamin dismisses the workers' perceptions as "not necessarily reality" and shows absolutely no interest in what has been done with the safety hazards noticed by 70% of workers and reported by 42% of workers.

This meeting exemplified the dangerous rut that Metro is in: (a) writing blank checks to demonstrate its response to NTSB recommendations designed to prevent a crash like the Red Line crash, while (b) placing their heads in the sand when anyone suggests that more safety hazards exist.

What exactly is the Board doing any differently than they did before the Red Line crash to demonstrate safety oversight?

Other than reviewing statistics of injuries and fatalities by month (which we all knew by reading the newspaper anyway), forming a Safety committee and changing the mission statement, it's unclear what is happening that is supposed to resemble safety oversight.

7 comments

WMATA Board not at fault for crash, but needs to step up (Jul 27, 2010)
Should NTSB recommendations get a blank check? (Sep 30, 2010)
Senators threaten WMATA takeover; NTSB holding hearing on June crash (Feb 23, 2010)
WMATA ex-GM presents assessment to Board (Mar 12, 2010)
Richard Sarles will make safety top priority, ride Metro (Mar 4, 2010)

Should NTSB recommendations get a blank check?

Thu, 30 Sep 2010 13:31:00 EDT

by Ken Archer

Following the June 2009 Red Line crash that killed 9 people, the NTSB made several recommendations to Metro based on the causes of the crash. While these recommendations are obviously important, Metro has an obligation to riders, and to the families of the victims, to ask what safety trade-offs would be made by implementing them.

What safety trade-offs could NTSB recommendations possibly have? There are several potential causes of fatality and injury in the Metro system, and saying 'Yes' to the NTSB recommendations means saying 'No' to addressing other safety risks.

Based on the most recent WMATA Safety and Security Committee meeting, however, the WMATA Board appears poised to hand out blank checks for implementing any NTSB recommendations, without even inquiring into trade-offs. If that happens, the result for riders will be more budget shortfalls, leading to bigger fare increases, and unnecessary safety risks.

Here's what has happened so far. Metro announced in July that it has set aside $30 million over three years to implement any NTSB and FTA recommendations following the June 2009 red line crash that killed 9 people.

However, when Senator Mikulski (D-MD) asked in August for cost estimates of each recommendation, the total provided by Board chair Peter Benjamin was $100 million. And that's just for recommendations for which Metro has cost estimates.

When Chief Safety Officer Jim Dougherty met with the Metro Board on Sept 16, not a single question was asked about the skyrocketing costs and trade-offs of implementing federal recommendations.

Actually, not a single question was asked about the details or trade-offs of any of the recommendations, from the $55 million replacement of Gen 2 track circuit modules to the $25 million safety analysis of the automated train control system.

The oversight meeting with Dougherty lasted for only 45 minutes, and consisted primarily of a self-congratulatory presentation on the progress made by WMATA, which included the new logo seen here.

To exercise safety oversight, the Metro Board must ask about safety trade-offs in every meeting: Why are the current safety actions, whether they originate from the NTSB or not, the highest safety priorities?

The FTA asked this question during their audit and was told that no prioritized list of safety actions exists. The answer to the Board should look something like the table below. In fact, this should just be added to the monthly Vital Signs report.

Hazard Tracking Log (HTL) Should be Added to Vital Signs.

This table is a Hazard Tracking Log (HTL). It's based on a similar table from a booklet called Hazard Analysis Guidelines for Transit Projects, published 10 years ago by the FTA. Lots of safety actions are prioritized based on the severity and likelihood of the identified hazard causing injury or fatality. Hazards and their corresponding safety actions are generated by 2 types of hazard analysis, reactive and proactive, which I describe elsewhere.

The non-NTSB recommendations in the table are empty because the Metro Safety Office has yet to conduct proactive hazard analysis for any critical system, as I've discussed elsewhere, and integrate the resulting safety actions into a prioritized list.

Most of the FTA's recommendations are focused on putting a Hazard Management System in place (basically, doing what the aforementioned booklet says to do) that consists of hazard analyses that continuously update the prioritized Hazard Tracking Log table. Metro's responses to FTA and NTSB recommendations, however, raise two serious concerns about its ability to put this System in place.

Metro is outsourcing hazard analysis of the Automatic Train Control system.

This $25 million, 3-year project, which is in response to an NTSB recommendation, was announced by Benjamin in his August letter to the Congressional delegation. That's a lot of money. $25 million would employ 75-100 engineers and analysts full-time for 3 years. One wonders what the WMATA safety office does if we are paying $25 million to contractors to do hazard analysis.

And what happens when the analysis ends, and we upgrade the automated train control system? Do we pay several million dollars again to a contractor to conduct another safety analysis? It seems like a good idea for the contractor to train and transition the safety analysis to WMATA's own safety office.

However, when asked if this would happen, a WMATA spokesperson responded, "The task will not specifically train Metro employees in how to conduct safety analysis, but will identify proper response and prioritization to safety concerns, particularly in an integrated environment."

Metro touts Hazard Management success without actually doing hazard analysis.

In Metro's August reply to the FTA audit, Metro merely copied the FTA recommendations (e.g. identify skills required for hazard analysis; train employees in these skills; etc) and pasted them into the HTL table shown above as a demonstration of progress.

Metro then announced triumphantly, "By evaluating the FTA recommendations in this manner, WMATA demonstrates that it has established a true hazard management program that incorporates a risk-based approach to evaluate and mitigate hazards".

This misplaced concern for the presentation of the results of hazard analysis, over the actual analysis itself, is even aired by WMATA's own IT department in the very same letter to the FTA. After discussing changes to the IT architecture being made to support hazard analysis, the following concern is said to be a "threat" to the entire project:

The System Safety and Environmental Management Department is awed by product suite success stories, dynamite product demonstrations and industry colleagues' evaluation of technology.

The FTA should not accept the responses of WMATA to its recommendations until WMATA has demonstrated its ability to actually do a hazard analysis of a complex system, which would enable it to then prioritize hazards in a system. It doesn't really matter which system it is—the elevators, the train doors, even the payroll system would be fine.

Metro can do this. It's my hope that, when the FTA begins regulating transit agencies, they will hold up Metro as an example for the rest of the country of world-class safety management.

But Metro can't do this and hand out blank checks for responding to NTSB recommendations regardless of the safety trade-offs. They are simply incompatible approaches to safety. The latter, reactive approach leads to budget shortfalls requiring fare increases, and to injuries and fatalities. The former, systematic approach leads to improved safety at the most efficient and rapid pace possible.

But Metro can only do this with leadership in oversight, particularly from Board chair Benjamin and Safety & Security Committee chair Mort Downey.

Kenneth Hawkins, brother of one of the killed passengers from the Red Line crash, asked following the NTSB hearing, "Who's going to hold WMATA accountable?" I still have the same question.

11 comments

Metro workers afraid to report hazards, Board unfazed (Oct 12, 2010)
WMATA Board not at fault for crash, but needs to step up (Jul 27, 2010)
Metro needs calm, proactive hazard analysis (Aug 4, 2010)
Senators threaten WMATA takeover; NTSB holding hearing on June crash (Feb 23, 2010)
NTSB blames track circuits, safety culture for Red Line crash (Jul 27, 2010)

Paying the price for safety

Fri, 03 Sep 2010 08:30:00 EDT

by Erik Weber

WMATA released its first cost estimate since the July NTSB recommendations. The fixes are estimated to cost nearly $1 billion. (Post)

Comment

Report card

Tue, 24 Aug 2010 10:11:00 EDT

by Erik Weber

More than a year after the accident, NTSB has released the final report on last June's Red Line crash. There's also a video reconstruction of the crash. (Sand Box John, Stephen Miller)

Comment

Metro needs calm, proactive hazard analysis

Wed, 04 Aug 2010 12:12:00 EDT

by Ken Archer

NTSB members' emotional tongue-lashing of Metro last week may have been well deserved. But the NTSB critique also risks being counterproductive unless cooler heads prevail at WMATA, focused more on actual safety than on just responding to NTSB.

Photo from the NTSB.

NTSB's safety recommendations are reactive, not proactive. They illuminate the facts of the crash, but are unhelpful in preventing the next crash, whose specific causes are likely to be very different given the rarity of accidents in any transit system.

Furthermore, because NTSB's makes its recommendations without regard to costs, yet expects WMATA to implement them in their entirety or suffer further tongue-lashing, they risk stealing funds from higher priority corrective actions. WMATA really needs a prioritized list of initiatives (corrective action plans, or CAPs) that would boost safety, without regard to whether NTSB has made political footballs of them or not.

Where should such a list come from? Hazard analysis, conducted systematically, is the central discipline in safety management, and it is missing at WMATA and from NTSB's recommendations. It is common practice in industries such as airlines and nuclear power.

A hazard is a cause of an accident, and the purpose of hazard analysis is to identify as many hazards as possible and then prioritize them by likelihood, severity of the consequences, and the cost of correcting them. There are two types of hazard analysis, and both are critical.

Root Cause Analysis: Whenever accidents happen, root cause analyses must be conducted to identify the root causes, or hazards, that led to the accident. NTSB conducted an excellent root cause analysis of the Red Line crash. The problem with relying on root cause analyses alone is that systems with very, very few accidents present few opportunities to identify root causes, and the root causes of each accident are statistically likely to be different.

Failure Modes and Effects Analysis (FMEA): A more proactive approach to hazard analysis is to identify all of the ways in which a system might fail. These are the system's failure modes. Loss of train detection by the automatic train control system was the failure mode implicated in the Red Line crash. But there are dozens of other failure modes. FMEA identifies as many failure modes as possible, identifies the causes of each failure mode, and then prioritizes the actions that would correct each cause by the severity and likelihood of the effects of their failure mode and the cost of the corrective action.

NTSB rightly identified the deeper cause of the Red Line crash as not the failure of track circuit modules but an institutional failure to address safety. This institutional failure, though, was unhelpfully generalized as the "lack of a safety culture." How does one get a "safety culture"? NTSB's recommendations are sorely lacking in detail on this topic, with no mention of hazard analysis or FMEA. The result, as has been said, is a tone of petulance by the NTSB.

When WMATA calmly, systematically begins to conduct hazard analysis, publicly displays the resulting prioritized list of Corrective Action Plans in its monthly Vital Signs report, and then updates the list itself (as hazard analyses are conducted continuously) and the status of each plan, then people will think of WMATA as having a "safety culture".

FTA Guide for Transit Hazard Analysis.

In this regard, the FTA was much more helpful than the NTSB in the FTA Audit's recommendations for a "Hazard Management Program". The institutional root cause of the Red Line crash, unidentified by NTSB, was described perfectly by the FTA: "There is no evidence that safety analysis is being performed to prioritize hazards for elimination and mitigation."

Will cooler heads at WMATA prevail? Preliminary signs are not encouraging. The WMATA Board criticized the failure to implement over 100 Corrective Action Plans. Similarly, a WMATA official told the Riders Advisory Council, in explaining why the new 7000 series of rail cars will forego longitudinal seating, that if there were anything it could do, no matter what, to improve safety, then they would be remiss in skipping it.

Both of these incidents portray a shell-shocked WMATA that is reflexively saying "of course" to any idea that could improve safety. This emotional response to safety is precisely what leads to the false "safety vs cost" trade-off. A proactive hazard analysis program, however, must prioritize this list of ideas because it has produced far more corrective action plans than there is money or time to ever implement.

This results in a lean safety agenda that prioritizes CAPs with a high safety return on investment, not those that will only push large volumes of riders into cars for a minimal improvement in safety. That's why the FTA asked WMATA for its list of "top ten" hazards that it plans to address.

Furthermore, it's unclear if FMEA and Hazard Analysis are skills that exist within WMATA. The recent WMATA Vital Signs monthly report of Key Performance Indicators, such as passenger injuries and bus on-time performance, is to be commended for transparently monitoring and reporting metrics. But the discussions of "Why did performance change?" and "Actions to improve performance" for each KPI seem so arbitrary that it appears no root cause analyses were conducted for each KPI that was below target. Hopefully new Chief Safety Officer James Dougherty can bring these skills to WMATA.

It's time for calm, proactive analysis to replace emotional, reactive safety initiatives. The Metro Board and GM, as well as journalists and bloggers, can be more helpful by asking the right questions, as the FTA did, instead of exposing every safety idea that WMATA has not implemented as indicative of an agency with no "safety culture."

18 comments

Should NTSB recommendations get a blank check? (Sep 30, 2010)
Metro safety presentation still doesn't prioritize (Oct 27, 2010)
Metro workers afraid to report hazards, Board unfazed (Oct 12, 2010)
Metro audit portrays isolated safety management (Oct 18, 2010)
The Price of Safety, part 1: Track workers face danger (Oct 2, 2009)

WMATA Board not at fault for crash, but needs to step up

Tue, 27 Jul 2010 14:06:00 EDT

by David Alpert

The NTSB's meeting on the 2009 Red Line Crash continued this afternoon with even more troubling revelations. They also criticized the Board's lack of safety oversight, which seems unfair for before the crash, but the Board does need to step up now that they know there are problems.

Dr. Loren Groff at the NTSB.

WMATA top management seems to have tragically ignored safety warnings and potential problems for years. The systems generated 8000 "alarms" from track circuit errors per week, but according to the NTSB, WMATA safety officials ignored these problems because they assumed the system was "failsafe."

Some train operators were instructed to run their trains on manual because there were problems with automatic operation, and operators were being punished for delays.

However, NTSB staff also blamed the Board for not doing more on safety. NTSB member Robert Sumwalt also repeatedly brought up the Board's role during questioning. According to one presentation by Loren Groff, they felt the Board should have not only asked tough questions of top management, but gone around them to conduct their own investigations into the safety operation of the organization.

That seems unrealistic. It's probably true the Board could have asked more tough questions. They could have commissioned an Inspector General's report. But they asked safety questions of the General Manager and got what seemed like satisfactory answers.

According to the NTSB discussion, the Board asked the General Manager to explain the top safety incidents and what was being done about them. The Board sees itself as a policy-making body, and doesn't meddle in day to day operations. Asking the GM for a safety summary seems like the right approach. If the GM's summary was misleading, it would be nice if Board members had psychically divined this, but it's hard to see how exactly they could have.

Sumwalt also criticized the way the WMATA Board has a committee on Customer Service, Operations, and Safety. "We at the NTSB only focus on safety," he said, "but that committee has to balance customer service with safety." Yes. It should. Customer service and safety are both important. The NTSB may have the luxury of ignoring everything but safety, but that doesn't mean that boards or agencies can do so.

The Board could have constantly asked the General Manager what the agency was doing to comply with NTSB recommendations, said Groff. But we know that many of those recommendations were financially unrealistic. The NTSB members might wish that everyone spent all their time sitting around and only worrying about safety and nothing else, but that's not how it works in reality.

Another NTSB member noted that in a hearing, ~~Board Chairman Peter Benjamin~~ previous Board Chairman Jim Graham said he hadn't heard of the Tri-State Oversight Committee before the crash, though then-General Manager John Catoe was well aware of it. But few of us out in the public had heard of it either. The TOC, by all accounts, operated in obscurity and for some strange reason didn't feel it could talk to the Board or the public.

We were all ignorant of the safety problems before the crash. Now, following investigations, it's clear that there were many organizational problems within WMATA, and the TOC wasn't functioning properly. I wish that the Board or other leaders had found out and fixed it, but it's hard to throw stones at leaders who only knew what we knew, and we didn't know about the problem.

The fault lies with General Manager Catoe and the safety officials at WMATA. Now, knowing this was such an issue, the Board does have a responsibility to ensure it gets fixed. Now, the Board should delve more deeply into the progress the agency is making on safety. Now, they shouldn't be satisfied with vague answers from management.

And now, if future crashes happen that could have been prevented, it would be fair to blame the Board if they don't take adequate action. I'm not sure that stepped-up level of oversight is happening. The NTSB said that even today, the Board doesn't claim responsibility for safety. They're right that this should change. It should start now.

Update: I've revised the headline and intro paragraph to reflect some further thoughts on what the Board needs to do going forward.

20 comments

Should there be two WMATA Boards? (Jul 28, 2010)
WMATA ex-GM presents assessment to Board (Mar 12, 2010)
WMATA to add safety committee, change mission statement (Sep 13, 2010)
NTSB blames track circuits, safety culture for Red Line crash (Jul 27, 2010)
Senators threaten WMATA takeover; NTSB holding hearing on June crash (Feb 23, 2010)

NTSB blames track circuits, safety culture for Red Line crash

Tue, 27 Jul 2010 12:06:00 EDT

by David Alpert

The National Transportation Safety Board is issuing their official findings from the June 2009 Red Line crash today. In this morning's session, they criticized WMATA officials, the agency's safety culture, and even the Board and Congress in the strongest terms.

NTSB animation of the Red Line crash.

They identify track circuit failures as the cause of the crash, and furthermore, these "parasitic oscillations" remain in 290 circuits. One circuit appears to have been failing consistently since 1998.

WMATA had announced they couldn't reproduce the problem, but according to the NTSB, Metro tested the circuit improperly. Had they done so, they would have seen the circuit fail to detect trains.

The NTSB created an animation showing the crash and the track failures.

The NTSB also criticized WMATA's decision to "belly" the 1000 series cars by moving them to the centers of trains, saying there hadn't been any "technical assessment" to determine whether this was actually safe. (Is this analogous to the decisions against longitudinal seating, also based on vague safety assertions?)

They reiterated their recommendation to replace the 1000 series cars, which WMATA will do with the Kawasaki order which, as of this morning, is now cleared to go forward. The NTSB said the 2000 and 3000 series cars are also susceptible to telescoping in a crash, but it's unclear what WMATA can do about it unless the federal government is interested in coming up with billions more to replace them.

DCist has a good summary of this morning's session. The meeting is now on break for lunch until 12:30. I will be tweeting the afternoon session @ggwash and will post about it again later.

Update: Steven Yates made a good point I also wanted to make but wanted to get the post out quickly:

"When safety is more important than schedules, their lessons will have been learned," said NTSB Chairman Deborah Hersman.
Placing aside for the moment how well WMATA keeps to schedules, I think this is flawed thinking. As we've discussed before, a decrease in the quality and reliability in regards to speedy transit will result in more people driving, which is much more dangerous than taking Metro.

Maybe they'll talk about this later, but there seems again to be no comparison of Metro safety to other modes. Saying the 2000 and 3000 series are not so safe is sure to make some riders nervous. It'd be great if those cars were more crash-proof, but is riding in them really something to avoid compared to driving?

The NTSB tends to focus on just how to improve the particular mode they're investigating at the time, but that carries problems. If they're going to make strong statements about the importance of safety, they should put it in some context rather than simply scaring people away from Metro.

23 comments

Recommendation to replace 1000 series wasn't ignored (Jul 28, 2010)
WMATA Board not at fault for crash, but needs to step up (Jul 27, 2010)
Senators threaten WMATA takeover; NTSB holding hearing on June crash (Feb 23, 2010)
How track circuits detect and protect trains (Mar 5, 2010)
Time to reaassemble railcars into single-series trains (Mar 15, 2010)

Line of sight not enough to prevent June 22 crash

Wed, 24 Feb 2010 10:26:00 EDT

by Matt Johnson

A National Transportation Safety Board (NTSB) sight-distance test shows that the train operator in the June 22 crash probably wouldn't have realistically seen the stopped train soon enough to prevent a collision when the signaling system failed.

Photo from the NTSB.

The operator appears to have applied the brakes less than three seconds after first "full sighting" when it was clearly visible, but that was still not early enough to prevent the collision.

This demonstrates that a working signaling system is absolutely vital to Metrorail safety. If the signal system fails, then manual operation does not necessarily protect trains from colliding.

While the final NTSB report on the collision is not likely to be published for several more months, the NTSB released documents and exhibits about the incident in preparation for this week's hearing.

According to the report, Train 112 was probably traveling at about 52 mph when the brakes were first applied.

Based on a report on track geometry, ambient conditions, and the braking capabilities of Train 112, it would have been possible for the train to stop prior to collision with Train 214 if the brakes had been applied at first partial sighting of the stopped train and also with a 3 second response time, even with a minimum brake application.

The first partial sighting of Train 214 was 1,121.5 feet. At this position and time of day, the stopped train is in shadow and is screened by the chain-link fence running alongside the Shady Grove-bound track. It is also obscured by the vegetation on the west bank of the railroad cut.

First partial sighting, from NTSB sight-distance test.

The report also shows braking based on first full sighting of the stopped train. This is 471 feet from the point of impact, a little more than the length of a 6-car train. Even an emergency brake application at this point would not have averted the collision, but would have slowed the train to about 24 mph. A three second-delay in response time would have resulted in a crash speed of 44 mph.

First full sighting, from NTSB sight-distance test.

Based on the steel bluing (skid marks) on the rails, the operator of Train 112, Jeanice McMillan, probably applied the brakes less than three seconds after the point of first full view, but not in time to stop the collision from occurring at at least 33 mph.

The NTSB identified a "last point" to stop after which a collision was inevitable. That point is about 400' after the first partial sighting, and about half the distance to the full sighting.

The collision happened around 15 seconds after the first partial sighting of the stopped train, or around 5 seconds after the first full sighting.

It is important to note that even when the stopped train came into view, it might not have been clear to the operator of Train 112 that the visible train was stopped on the Shady Grove track (Track 2). This was reported to be a factor when a Metro train struck wayside workers at Eisenhower Avenue in November 2006 (page 5).

These tests show the importance of the ATC system. Line-of-sight often does not present enough time or distance to stop trains, which is why railroads and transit systems use signal systems. It is absolutely vital that fixes for the ATP train detection system be found.

In past discussions, some commenters have wondered about color-light signals as a solution. It appears that in this case, they would not have made much difference. The track circuit where Train 214 was stopped failed to detect Train 214. If color-light signals had been present, they would have displayed a "clear" aspect in the same manner that the ATC system sent "clear" to the cab speed signals on Train 112.

If WMATA and its passengers cannot be confident in the train detection system, there can be no true confidence in passenger safety. That's why it is so important to design and implement at least one backup system. San Francisco's BART did so in the early 1970s, and WMATA tells us that they are working on a system now. WMATA hopes that such a system can be in place by the end of this calendar year. For riders, that system cannot come soon enough.

41 comments

A look at Metro's safety systems (Jun 24, 2009)
How track circuits detect and protect trains (Mar 5, 2010)
NTSB blames track circuits, safety culture for Red Line crash (Jul 27, 2010)
Senators threaten WMATA takeover; NTSB holding hearing on June crash (Feb 23, 2010)
Metro crash roundup (Jun 23, 2009)