Thread by @MetrorailSafety

Today’s meeting includes an update on ongoing investigative work, votes on adoption of a number of final #WMATA safety event investigation reports, other oversight and audit updates & more
Watch live starting at 12:30 wmsc.gov/meetings/

We are proud to offer closed captioning to make this meeting more accessible. If you want the option to turn the captions on/off, please join us through Zoom.
Also join through Zoom webinar link here if you would like to participate with public comment wmsc.gov/meetings/

Join us on YouTube now for our public meeting on our #WMATA oversight work:

WMSC Safety Officer Richard David safety message:
1. Get your flu shot
2. Wear face coverings, wash your hands & social distance - #COVID19 remains a threat
3. Careful about Halloween
4. Daylight Saving Time ends next weekend – check your smoke/CO detectors & heating sources

Now on to public comments (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 begin with a tribute to his friend and fellow former NTSB Chairman, WMSC Commissioner and first ever Vice Chair Mark Rosenker who died last month

Chair Hart: I would like to take a few moments to honor our professional colleague and a treasured friend, Commissioner and Vice Chairman Mark Rosenker

Mr. Rosenker had a distinguished, and wide-ranging career that included serving in the Air Force and Air Force Reserve, the White House, the NTSB, and here at the WMSC. He also was a CBS News transportation safety analyst, and worked at the United Network for Organ Sharing

Chair Hart: For me, personally, Mark was also a great friend even before he became a colleague. I first met him more than 40 years ago, when we happened to live in the same condo complex here in the District.

Chair Hart: Mark made significant contributions to transportation safety and to many other areas, and we are confident his legacy will live on.

We would like to again send our condolences to Mark’s wife Heather and to the many friends and colleagues whose lives he touched.

CEO Mayer reflects on long history with Mark Rosenker as a great leader, commanding voice; and someone who reached out immediately in times of need

Chair Hart: Ahead in today’s meeting: Updates on ongoing investigations, several final investigation reports, ROCC CAP updates & more

CEO David Mayer: I would like to start with several updates related to the Oct. 9 train separation on the Red Line between Union Station and NoMa-Gallaudet Station.

CEO Mayer: WMSC staff responded to scene Oct. 9, have participated in hands-on review of coupler assembly that pulled apart, a number of interviews; emergency response and evacuation is a part of the investigation.

CEO Mayer: Among preliminary issues identified, customers were evacuated through side doors rather than bulkhead required by Metrorail procedures. Also examining duration of event, the decision making process regarding third rail power, and emergency response protocols

CEO Mayer: Metrorail does not have a procedure that defines the process for moving trains that experience damage from a pull-apart.

CEO Mayer: As for preliminary findings on the pull-apart, WMSC examining whether there is evidence properly calibrated tools were used for things like torqueing parts of coupler during preventive maintenance/overhaul, and whether proper parts were used in this assembly

CEO Mayer: Our initial assessment of the evidence suggests that the pull-apart likely occurred due to an improperly torqued bolt. The lack of damage to certain parts of the rail car suggests that the clamping bolt likely worked its way loose over time.

CEO Mayer: We are reviewing safety certification and implementation for a related 6000 Series rehabilitation and inspection plan that was developed after a similar pull-apart in 2018 on the Silver Line near the McLean Station. It was meant to prevent similar future events

CEO Mayer: Metrorail held all 6000 Series railcars out of service for inspections. By the middle of last week 90 percent of the fleet had been inspected. 18 of first 166 inspected had potential concerns. 3 appear to have had incorrect hardware.

CEO Mayer: The investigation has raised another, broader issue that is concerning to us, which is leading us to issue a new finding to Metrorail today requiring a corrective action plan.

Our review of the coupler assembly the morning after the pull apart showed Metro had not followed its own investigative procedures regarding the chain of custody for evidence. A bolt had been torqued after the event without approval from WMATA’s Safety Department and the WMSC.

CEO Mayer: We have since learned that a torque check was conducted the night of this pull-apart. This was done without any notification to the WMSC or WMATA safety investigators as required by Metrorail’s applicable Standard Operating Procedure.

CEO Mayer: This is not the first time we have identified issues with the chain of custody of evidence or inappropriate handling of evidence related to Metrorail safety events.

Similar concerns in the ROCC Audit & investigation W-0042 (Largo tail track collision)

CEO Mayer: Largo Trail Track was someone directly involved in event; ROCC recordings/reports access involved people in supervisory roles

This concern crosses all aspects of Metrorail.

CEO Mayer: Therefore, we are issuing a finding today requiring Metrorail to develop and implement a corrective action plan that will ensure all proper steps are followed to protect the integrity of all investigations into safety events. wmsc.gov/wp-content/upl…

CEO Mayer: This corrective action must include steps to ensure all Metrorail personnel understand their roles in events that trigger investigations. wmsc.gov/wp-content/upl…

CEO Mayer: A holistic safety approach includes not only sufficient and up-to-date written policies, but also proper training for the people who need to implement those policies, and a process to verify that these are being followed.

Under the WMSC Program Standard, Metrorail has up to 30 days to propose a corrective action plan to address this finding.

CEO Mayer: These safety improvements are particularly important as WMATA transitions into a Safety Management System (SMS) approach required under a Public Transportation Agency Safety Plan.
Metro Board plans to approve its PTASP this week so it can come to WMSC Board next month

The WMSC has provided extensive guidance to WMATA throughout the PTASP development process, and WMSC commissioners have had the opportunity to review drafts during this process

PTASP processes and lessons learned were part of a three-day @FTA_DOT workshop earlier this month that the WMSC staff and some commissioners participated in as part of a national state safety oversight conference

@FTA_DOT Opportunities like that conference and ongoing Transportation Safety Institute training are just some of the ways that we make sure our staff are always learning and growing to make our oversight the best that it can be.

CEO Mayer: We are continuing to take all possible steps to keep our staff safe amid the public health emergency.

CEO Mayer: As we take protections for our own staff, we are also in regular contact with employees at all levels of the Metrorail system

CEO Mayer: When anyone at Metrorail raises any safety concern to us – including about COVID-19 precautions – we follow up on those concerns with Metrorail to ensure that any safety issues are addressed, and we monitor those issues through our regular inspection process.

We are still in a public health emergency, and it will remain important for months to come that everyone continue to wear face coverings, keep their distance from each other, and follow all other precautions

The cycle of identifying hazards, mitigating or correcting the issue, and monitoring those mitigations is a crucial part of the SMS approach that Metrorail must implement as part of the PTASP.

We encourage Metrorail employees and contractors to report any safety concerns to WMATA’s Safety Hotline, and we encourage employees, contractors and members of the public to continue to report safety concerns to us at the WMSC via email, phone, social media or our website.

This type of SMS approach of identifying and mitigating hazards is also required to cover Metrorail’s safety certification process.

The WMSC learned last week that some individuals within Metrorail were planning to conduct a test of automatic door operations this month on the Red Line, without providing complete information to the WMSC or to WMATA’s Safety Department.

We informed the Chief Safety Officer of the uncoordinated plans to re-launch auto doors. We have been assured no testing will occur until the WMSC gets a comprehensive briefing and all Metro processes for safety assurance have been completed

CEO Mayer: The WMSC wants to be sure that appropriate safety certification activities are conducted as part of any future auto doors testing or restoration.

CEO Mayer: Regarding Metro’s Rail Operations Control Center, we are continuing to provide input and get insight into the broad reform processes that Metrorail has implemented in response to our findings dating back to December of last year.

CEO Mayer: WMATA began acting on a larger scale on this front following our May findings. They are required to submit proposed Corrective Action Plans this week to address the 21 additional ROCC Audit findings.
We have had an extensive dialogue with Metro about these CAPs.

Our staff will examine the details of the proposals to ensure that, once implemented, they will address the safety gaps - identified in the audit. We will also examine proposed timelines to be sure that Metrorail intends to implement these plans as soon as is reasonably practical

CEO Mayer: On safety certification, our team continues oversight work on the Silver Line Phase 2 extension.
The Metropolitan Washington Airports Authority is already in the process of addressing most of the issues identified in our Fire-Life Safety Assessment earlier this year

CEO Mayer: 2nd part of review will be done later on WMATA’s preparedness to operate & maintain.
Metrorail may not begin Silver Line Phase 2 revenue service until it completes its safety certification process and the WMSC concurs that was conducted properly and completely

Safety event investigations are up next – 3 on the agenda today

First, Operations Expert Bruce Walker and Program Specialist Adam Quigley presenting on a 2/4/20 smoke event at L’Enfant Plaza

Walker: Despite the smoke, a train carrying customers was sent through the area for the operator to conduct a track inspection.

The event began when ATC personnel attempted to cut a lock off a former employee’s locker in the Train Control Room with a grinder, which caused sparks to enter computer equipment.
The crew should have used a bolt cutter.

The supervisor involved did not conduct a job safety briefing and did not have hot-works training. The investigation also found there were no work instructions for removing a lock.

After the smoke began, ATC crew cut power to equipment fan and used a fire extinguisher
They opened the doors of the train control room for ventilation, which led to smoke exiting into the tunnel area near the platform. The smoke alarm in the train control room did not activate.

Quigley: The WMSC identified inconsistencies in the information going to the MOC desk compared to the ROCC Assistant Superintendent desk.

The call from the ATC employee to MOC was urgent and the caller stated smoke was in the train control room. Caller asked that fans be activated in the station to keep smoke away from platform. A Metro Transit Police officer also requested fan activation in station.

When the ATC employee was transferred to the other side of the room, the caller was much calmer.
At 11:55 a.m., the fans in the station were activated on exhaust.
It is unclear what specific information was conveyed to the ROCC controller from the Asst Super

ROCC told Train 309 at Gallery Place to perform a track inspection to L’Enfant Plaza on Track 2 without instructing the train operator to offload prior to proceeding through the reported smoke on the roadway.

The train operator was not told to look for smoke, but only to check for anything unusual.
The train operator reported a good track inspection at 11:59 a.m.

The ROCC Assistant Superintendent in charge during the incident claimed after the event that because the smoke was initially reported in the train control room, should not be treated as smoke on the roadway

The Assistant Superintendent and ROCC management at the time supported the decision to send a train with passengers through an area where smoke was reported.

This is a violation of track inspection procedures and SOP 6 governing smoke on the roadway.

SOP 6 requires the ROCC to instruct a train operator to offload a train and perform a track inspection if there is a report of smoke

The WMSC conducted an extensive investigation into this event to determine whether any other trains were also sent through the area in violation of SOP 6.

The WMSC’s review of interviews, telephone and ambient audio recordings, and other information shows that Train 309 was the only train sent through the area in violation of SOP 6.

Two other trains that we were initially concerned about were not part of this incident. Both remained in areas outside of the area where the smoke was identified and contained.

In this event, ROCC management did not remove those who may have played a role in the violation for post-incident testing.

As a corrective action for the ROCC, WMATA cited only a directive they said was issued several months earlier due to our findings regarding chaos and dysfunction during unplanned emergencies.
WMATA could only provide evidence some ROCC employees received that document.

Although the corrective action falls short for this event, the WMSC will ensure Metrorail incorporates steps to prevent a similar situation in the future into broader Corrective Action Plans proposed as part of WMATA’s required actions stemming from the ROCC Audit

Walker: Metrorail issued a more substantive lessons learned document for ATC Maintenance that explicitly barred any work in a train control room that involves sparks emitting from tools. ATC Maintenance also now required to take computer-based hot-works training

Bruce Walker also presenting the next investigation report, improper roadway worker protection (RWP) on the BL/OR/SV tracks between Rosslyn and Foggy Bottom on July 11

Walker: a track inspection crew asked for and received permission to walk from Rosslyn toward Foggy Bottom, through the tunnel under the Potomac River. Initially, they had Advance Mobile Flagging (AMF) protection

While that level of protection was appropriate for part of the segment, WMATA RWP rules identify a more dangerous area in part of the tunnel where additional safety measures are required for approximately a quarter mile

Although in many parts of the system these “hot spots” are due to reduced sightlines, in this location the Access Guide warns of a potential turbulent air vortex if trains continue to move through the area, creating a danger even if workers are up on the safety walk.

Because of that hazard, workers are required to request and be granted Foul Time to traverse this area (protection established using red signals and radio announcements to stop trains on a given segment of track)

In this event, the workers proceeded through the “hot spot” area without anyone on the crew raising a concern and requesting foul time.
A ROCC controller recognized Foul Time should have been requested when the crew reported over the radio they had safely reached Foggy Bottom

The Roadway Worker In Charge then suggested the crew may have been too focused on inspection work, losing situational awareness regarding their location on the tracks. The RWIC said that the hot spots had been covered in the job safety briefing.

Walker: This could suggest that Metrorail’s training is not effectively communicating the risks personnel face when traversing hotspots that do not have restricted views, such as a location like this where there is a risk of a turbulent air vortex.

The RWIC was retrained on Roadway Worker Protection procedures.
Metrorail’s Safety Department also suggested WMATA install signage to indicate where Foul Time is required, and recommended that an individual be specifically tasked with identifying hot spots.

Walker: The specifics of changes like those are up to Metrorail to determine and implement in an acceptable way.
However Metrorail chooses to address it though, the WMSC wants to ensure that RWP rules are followed.

Walker: Job safety briefings need to be more than just checking a box, and everyone on each crew and their supervisors must be vigilant and aware, and must be provided a clear understanding of why specific hot spots are considered dangerous and why Foul Time is required.

Walker: Such understanding could be provided through safety stand downs focused on the importance of Foul Time even in hot spots with a clear view.
Metrorail should also ensure that work crews are never inadvertently encouraged to operate without proper protections.

Walker: This event is one of those that Metrorail has included in a safety stand down for all RWP-qualified workers that is continuing this week. The stand-down addresses RWP procedures and safety events, as well as safety issues raised in our recent audits and oversight work.

WMSC Vice Chair Hull praises the safety stand down as important to make sure that everything is clear & followed

Jemayne Walker, Track and Structures Expert, is presenting our final investigation report for the day involving an injury at West Falls Church during this summer’s major construction

Walker: A contractor employee suffered a broken leg on August 5, 2020. A work crew was moving water-filled barriers that had not been completely emptied as they should have been for any lifting or other movement.

The work crew also double-stacked the barriers, when the barriers should not have been stacked.
The barriers should have been lifted with a choke hitch, but were instead lifted with a basket. The crew also did not leave appropriate space for themselves in case the barriers fell

Walker: This crew working on the Orange Line summer shutdown project did not properly plan their work, and Metrorail did not properly oversee contractor work plans.

Walker: Kiewit also did not follow WMATA’s Drug and Alcohol Policy regarding post incident testing, and Metrorail did not ensure compliance with that policy to ensure all involved workers were tested

Walker: The company conducted a safety stand-down regarding lifting and rigging work, and incorporated information from this event into daily safety briefings.

Walker: Metrorail should conduct daily surveys of construction projects to ensure proper oversight of contractors and to verify contractor work plans; and must ensure contractor compliance with drug and alcohol testing

Audit updates from Audit Manager Davis Rajtik: Metrorail’s Corrective Action Plan proposals for the 21 findings issued in last month’s ROCC Audit are due this week.
Our team has been in regular contact with Metrorail about these proposals.

We will evaluate each proposal to be sure that, once WMATA implements the corrective action, each plan will fully address the related finding in a timely fashion.
We have approved CAPs for implementation on the four other ROCC-related findings issued in Dec/May

Rajtik: We are now finalizing the report on our Audit of Elevated Structures Inspection, Maintenance and Training. We expect to be able to issue and publish this report before the end of the year

Rajtik: We are also just beginning our work on our next audit of Roadway Maintenance Machines, covering all rail vehicles other than the rail cars that are used in revenue service.

That concludes today’s meeting. You can always reach out to us here, on Instagram instagram.com/metrorailsafet…, on Facebook facebook.com/MetrorailSafet…, through our website wmsc.gov/report/ or via email

The three final safety event investigation reports adopted by WMSC Commission today are available on the investigations page of our website: wmsc.gov/oversight/repo…