Thread by @MetrorailSafety

Today’s meeting includes an update on the investigation into last month’s derailment at Silver Spring, votes on adoption of a number of final safety event investigation reports, ROCC status report & more
Watch live starting at 12:30 wmsc.gov/meetings/

We are proud to offer closed captioning to make this meeting more accessible. As always, you can watch on YouTube. If you want the option to turn the captions on/off, please join us through Zoom.
Also join through Zoom to participate with public comment wmsc.gov/meetings/

Join us here on YouTube for our remote public meeting on our #WMATA oversight work

WMSC Safety Officer Richard David has our safety message:
#COVID19 is still here & still spreading
Wear your mask, wash your hands, social distance

WMSC’s Richard David outlines keys for emergency response:
Always be prepared, have a plan
Team effort, 24/7
Takes coordination
Clear instructions
Safety is the priority - and our focus as we conduct our oversight and enforcement work

Now on to public comments - none today. (You can always reach out @MetrorailSafety here, on Facebook, Instagram, via email or through our web form wmsc.gov/report/)

Chair Christopher Hart opening remarks: Welcome new alternate commissioner, just confirmed by D.C. Council, Victoria Wassmer. She has decades of experience at FAA, OMB, DC City Administrator’s office & more

CEO David Mayer: First, an update on today’s heavy rainfall: We have been monitoring any safety concerns related to water infiltration or flooding

Metrorail closed the Cleveland Park station today due to flooding concerns. We appreciate that proactive step to avoid something like we saw in 2016 with flooding occurring as customers attempted to exit. We are aware of DC’s long-term work planned in the area

Metrorail also closed one entrance at King Street and placed sandbags in some areas.

Be especially cautious today and aware of your surroundings with the heavy rains from #Isaias

CEO Mayer: WMSC staff continue to follow safety protocols regarding social distancing, and we are emphasizing the use of electronic data and remote interactions whenever possible. Still, there are times where in-person inspections or investigations are best.

CEO Mayer: 2 WMSC experts immediately responded to July 7 derailment on the Red Line in Silver Spring. They followed social distancing guidelines and gathered important information for our investigation.

Mayer: The WMSC participated in interviews with the train operator, rail controllers and other #WMATA employees. We have also reviewed video, audio and signal system recordings.

CEO Mayer: Operator of Train 108 moved the train past a red signal at the north end of the Silver Spring platform just as the Rail Operations Control Center was sending a command to move the switch associated with that signal back to a normal position

Mayer: Due to the timing of the train passing the red signal, the lead car headed into the pocket storage track. The switch moved under the train, derailing the lead trucks of the second car

Mayer: We are also investigating apparent #WMATA radio equipment and communication failures following the derailment. (On top of the flooding that was already disrupting Red Line that day)

CEO Mayer: As the emergency response began, recordings inside the ROCC show a controller was providing instructions, but those instructions did not properly transmit over the radio. It appears that this was due to an equipment failure such as a defective microphone

CEO Mayer: WMATA Office of Emergency Management employee who was functioning as fire liaison on day of derailment did not properly communicate with first responders on the scene.

CEO Mayer: A backup, cell phone-based connection to fire department radio systems was not available to that liaison at Metro HQ. Phone was at the main ROCC facility in Landover, but alternating schedule had this shift downtown

CEO Mayer: Our investigation will continue to look into root causes and exact timing of actions in this event, and what changes could be made to improve safety in the future.

CEO Mayer: Regular staffing of fire liaison position by uniformed officers of local fire departments resumed July 19

Also July 19, WMATA ended alternating ROCC shifts between facilities, and ended alternate day schedules for maintenance crews

#WMATA plans to restore some rail service across the system on Aug. 16 including more regular train frequencies, partial hours restoration, and reopening of Va. Silver Line stops.

Shorter summer shutdowns (currently on Red Line) will also end

The last Orange Line stations closed since May are due to reopen around Labor Day. The WMSC is overseeing Metrorail’s safety certification process for reopening those stations.

The WMSC is also overseeing Metrorail’s practices regarding the return of railcars to service that had been shut down due to the health emergency.

When our inspections or investigations identify concerns tied to the use facial coverings or similar health-related issues, we quickly share those instances with Metrorail for correction.

We continue our oversight work related to Silver Line Phase 2. We will be conducting pre revenue service reviews that track the fixes to issues we have already raised and that will identify any final issues as the project is turned over to WMATA and then readied for riders.

MWAA has committed to addressing the observations in our Fire-Life Safety Assessment we formally transmitted in June.

MWAA hopes construction can reach substantial completion around the end of this year.

CEO Mayer: Among our focus areas for that review of WMATA’s readiness to open Silver Line Phase 2 to customers will be whether Metrorail has adequate staffing and training in place to run the line safely.

Metrorail provided a response to us last week that outlines some of the current hiring efforts and planning assumptions for Silver Line Phase 2, but we continue to seek additional information on this front.

CEO Mayer: One area that could pose a particular concern to the WMSC for Silver Line extension opening is staffing and training in the Rail Operations Control Center.
Safety issues in the ROCC have caused significant concern for us over the past year or so.

CEO Mayer: After months of direction from the WMSC, Metrorail’s latest draft corrective action plan linked to our finding from last December on the dysfunction and chaos in the ROCC appears to have moved in the right direction.

CEO Mayer: May ROCC findings on rushed, unsafe power restoration; remote console manipulation; lack of vent fan understanding

In June, after follow up discussions, WMATA reassigned ROCC Director

CEO Mayer: Metrorail has also committed to increased involvement in ROCC changes at the General Manager and WMATA Board level.

CEO Mayer: Our months of audit work on the ROCC is now substantially complete, and we hope that our extensive findings will shape this transformation.

CEO Mayer: We are sharing the draft ROCC Audit report with WMATA this week as required by our Program Standard, and we anticipate that we will finalize and release the report to the public in early September.

CEO Mayer: Review and approval of WMATA’s Public Transportation Agency Safety Plan (PTASP) coming this fall -- must implement a Safety Management System approach, which has long been used in the aviation industry.

CEO Mayer: Our staff have been in regular communication with Metrorail about the status and content of the PTASP to ensure the final plan complies will all safety requirements. This week, we expect to receive the final substantive revisions we directed Metrorail to make.

CEO Mayer: I want to praise WMATA’s Fire Marshal for quickly correcting issue raised through our safety concern web portal (wmsc.gov/report/ - one of many ways customers, employees, contractors and anyone else can let us know of safety concerns in the Metrorail system)

CEO Mayer: email identified incorrect emergency exit signage on the platform at DCA. We raised the issue with the fire marshal, and the signs were corrected within 24 hours to read “authorized personnel only”.

CEO Mayer: FTA has concurred with WMSC's Title VI program. WMSC also on track to meet DBE goals, which FTA has also concurred with

CEO Mayer: Annual reports approved in June have been distributed and remain available online wmsc.gov/oversight/annu…

CEO Mayer: Improved safety event notification matrix approved in June is now fully implemented and is providing better data and improved notifications

Next up: Investigation reports.
Commissioners approve 2 on consent agenda and move on to a July 8, 2019 derailment investigation presented by WMSC Track and Structures expert Jemayne Walker

7/8/19 hi-rail vehicle derailment in Blue/Yellow Line shutdown area near Van Dorn Street. Contractor reported going about 2 mph, derailed about 20 feet from switch point

There were challenges in this investigation due to Metrorail’s reliance on the contractor for much of the internal investigation of this incident.
The contractor also re-railed the vehicle before a safety officer arrived, and the notification process was delayed.

With information available, the investigation shows that the rear road tires likely climbed the guard rail at the switch, leading to the derailment.
Airbags on the underside of the vehicle were significantly overinflated. >40 psi when should be <20 psi (pressure was not checked)

As corrective actions, Metrorail said contractor would correct pressure on this vehicle and include checking airbags on future pre-move checklists.
Contractor also offered, at WMATA’s request and WMSC’s insistence, to establish a protocol to handle future derailments.

Next is another hi-rail derailment in the Blue/Yellow Line shutdown area last summer. 8/27/19 near Alexandria Yard entrance

Again, Metrorail left its internal investigation of this incident to the contractor. In this case though, required notifications and communications were made in a much more timely fashion following the concerns we had expressed about the prior derailment.

Next, a third hi rail vehicle derailment in last summer’s Blue and Yellow Line shutdown zone – this one on Aug. 30, 2019

Contractor report described this flat cart as “chattering” then hopping off the track
Normally, this type of flat cart with rigid frame, no suspension is not permitted in the Metrorail system, but Metrorail made an exception for the summer shutdown area.

Metrorail failed to notify the WMSC of the derailment before the car was re-railed. In part, this is because Metrorail’s Safety Department also did not get the opportunity to respond to the scene before the vehicle was moved.
This again limited the investigation.

Next investigation is a hi-rail vehicle derailment in West Falls Church Yard on 9/26/19
Van got a flat tire while doing ultrasonic rail testing, after returning to yard and by time of derailment tire was shredded

Damage to vehicle rim; Rail had significant side wear.
Corrective action includes putting spare tire and rim on unit so it can be repaired in field if this happens again

Next: New Carrollton Rail Yard grade crossing collision on 10/23/19

The white WMATA van on the left was struck by the flatcar on the right as the van moved through the grade crossing closest to the entrance to the yard.
Flatcar was being pushed by prime mover

The flat car stopped for about 20 seconds at the crossing. Van driver went through stop sign as flat car began to move forward. Driver said he interpreted flag person proceed signal to equipment operator as proceed signal for van

Van totaled. Corrective actions include ATC lessons learned document and Metrorail-wide safety bulletin highlighting roadway grade crossing safety & rules

Drivers are required to follow posted signs; Equipment operators & flag persons required to use positive radio communication; Flag person must be ready to emergency brake; Operators must sound horn

Now WMSC Operations Expert Bruce Walker to present investigation on 1/4/20 collision in Car Maintenance Shop at Shady Grove

Four-car train operated from third car (which may not have been necessary) did not perform safety stops in the shop. Flag person radioed to stop, train operator did not stop. Continued until hit and coupled with stationary car

Flag person did not activate emergency brakes, and there was no communication between Interlocking Operator and Car Maintenance. Investigation found gaps in policies/procedures on third-car operation

Corrective action includes revision to & updated training on SOP governing movement of railcars into maintenance facilities. Require clear roles and responsibilities + requirement car maintenance personnel be in position to communicate through window as fail-safe

Next up: 8/15/2019 train collision at Largo tail tracks

After performing two of the four required safety stops, the train accelerated to more than 10 miles per hour. The train operator then applied emergency braking approximately two seconds before colliding with a stationary 3000 Series train.

The investigation shows the moving train was going about 5.8 miles per hour at the time of the collision. This moved the stationary train approximately one foot.

The train operator reported the collision, but attempted to alter the scene.

In violation of Metrorail rules, the train operator entered the stationary train and keyed it up, or turned it on, and attempted to decouple the trains.
This action was not successful, and investigators arrived on scene a short time later.

This collision damaged couplers, anti-climbers and shear bolts on the trainsets.
The investigation also identified a number of other safety concerns.

Video shows train operator had a smartwatch in violation of electronic device policy.
Following this & Oct. 7 collision, WMSC required improved enforcement & monitoring. New policy has been issued. WMATA now required to conduct random checks for devices

Video shows train operator used sun visor built into 7000 Series to block inward facing camera in a deliberate way. Train operator blocked a camera with the sun visor at least 3 times on the trip that led to the collision and the trip prior.

This was another example of an issue our inspections had identified in the weeks prior, of the sun visors being used to block the inward facing camera.

WMATA’s car maintenance team identified this as well, and began work to fix.
The WMSC ordered a Corrective Action Plan to prevent this from happening in the future by retrofitting the sun visors. We highlighted the issue at our September 2019 public meeting.

Replacement of the 7000 Series visors has slowed due to parts availability. As of the end of May, 208 out of 374 7000 Series cabs done. Now expected to be completed by the end of year

#WMATA must also incorporate the sun visor changes into the 8000 Series procurement

Other corrective actions arising from this collision include a notice to WMATA personnel highlighting the importance of safety stops and the re-distribution of WMATA’s electronic device policy.

For our final investigation report today, it’s back to WMSC Track and Structures expert Jemayne Walker.

Two Metrorail employees were hurt when rail fell on them on the Red Line 10/19/19 between Dupont Circle & Woodley Park

A Rail Production Renewal Crew was working on Track 2. Replacing rail involves “threading” – moving pieces of rail – using a vehicle, then clipping new rail in place.

In this case, part of a 1,200 foot long section of stringer rail that they had just removed tipped over and fell on two workers’ feet.

One worker who the rail fell on had minor bruising, while the other suffered four broken bones in the foot.

These injuries happened because the length of the section workers cut was not manageable, and because the workers began to clip the new rail in place when the vehicle moving the old rail was out of sight – NOT when the vehicle moving the old rail had completed its work.

Recordings revealed no radio communication between the equipment operator and the Roadway Worker In Charge. There appears to have been no clear direction on when it would be acceptable to leave a point of safety and return to work.

The workers returned to the new rail to begin clipping it after the maintenance vehicle moving the old rail disappeared around a curve about 900 feet away.

As the equipment operator attempted to adjust the old rail around wooden forms left around grout pads due to prior concrete work, the old rail flipped on its side, wedging the feet of the two workers hundreds of feet away.

The equipment operator noted the wooden forms before starting but believed they would not pose any risk.
Corrective actions include revising and reviewing work procedures for this task to address safety issues. This includes reviewing training information and processes.

Audits update from COO Sharmila Samarasinghe: Draft audit report on Rail Operations Control Center is now complete. Transmitting to WMATA this week for required 30-day technical review. Expect to issue final report in early September.

On ROCC findings from Dec. 20 (chaos, dysfunction), May 12 (power, fans, remote manipulation): We have provided extensive feedback to Metrorail requiring improvements to their proposed corrective action plans

We are making some progress as WMATA works to fine tune a number of its proposed ROCC CAPs. However, we have not yet approved these CAPs and continue to require important revisions to achieve the intended safety improvements in a way that will be both timely and lasting.

We have just begun the formal audit process of Metrorail’s elevated structure maintenance and inspection.
We moved this audit forward due to concerns raised by other inspections and investigations.
WMSC staff plan to conduct significant parts of the audit work into the fall.

The adopted final inspection reports are now posted on our website: wmsc.gov/oversight/repo…

And that’s it for this month’s public meeting. Thank you for joining us. Our next meeting is scheduled for September 22.