Thread by @MetrorailSafety

Today’s WMSC meeting includes an update on ongoing investigative work, votes and presentations on 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

Chair Hart notes COO Samarasinghe will be handling CEO remarks today in CEO Mayer's absence

Today’s safety message from our Emergency Management Specialist Richard David: Wellness is just as important as physical safety. A good diet plays a big part in overall health. Make plans to exercise and stay hydrated - both can help both your physical and mental health

Safety message (2/2): Watch over your family and friends.

Covid-19 has made these challenging times, but we are beginning to overcome them.

Continue to wear your mask, social distance, and wash your hands often.

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 Hart remarks: First, I would like to thank WMATA’s General Manager and Board Chairman for taking time out of their busy schedules to meet last week

Chair Hart: I believe that the most productive relationship between a regulator and the regulated is a collaborative relationship, fueled by the shared desire of both WMATA and WMSC to improve safety.

Chair Hart: The purpose of our meeting was to discuss opportunities to improve the effectiveness of the collaboration, and I would like to thank them for making that meeting so productive. I look forward to future meetings with them from time to time to continue that conversation

Next, a resolution designating COO Sharmila Samarasinghe as acting CEO during Dr. Mayer’s leave of absence for a sudden personal issue, retroactive to Feb. 17 – approved unanimously

Chair Hart thanks Commissioner John Contestable for his exemplary service. Commissioner Contestabile is stepping down after moving out of Maryland. He was instrumental in helping to stand up the WMSC, and to getting staff on board & operating effectively. We wish him the best

(Alternate Commissioner Al Khatib is present and will participate as a voting member today given the vacancy)

Chair Hart: Ahead in this meeting:
- update on investigations & oversight activities
- 7 final investigation reports
- CAPs, Audits
- resolutions

Acting CEO Samarasinghe: I’d like to start with an update on ongoing investigative activities in the Rail Operations Control Center (ROCC)

We appreciate that Metrorail has identified positive paths for long-term change in the ROCC through CAPs we recently approved for implementation. We understand these will take time given the scale of the safety concerns we found. But we are also monitoring current activities

Through the WMSC’s regular oversight work, we identified new safety concerns related to power restoration, deliberate deviation from safety procedures, and a lack of WMATA oversight and quality control in the ROCC.

Samarasinghe: it was rushed power restoration by ROCC management in contravention of written procedures that got us focused on this issue almost 15 months ago, leading to 25 ROCC-related findings since December 2019.

Samarasinghe: The WMSC identified in January of this year that there were again deliberate deviations from power restoration procedures

Our investigation so far indicates that this is linked to some ROCC managers directing these deviations from procedures without any consideration for, or analysis of, the safety implications.

Samarasinghe: WMATA did not identify this was occurring, and only became aware because the WMSC independently identified and raised this safety concern to ROCC management. The WMSC also informed the Safety Department and General Manager so this could be corrected and prevented

Samarasinghe: On several days since January 20, the WMSC found Metrorail did not follow its approved power restoration procedures for “red tag” outages. These procedures were violated dozens of times at the direction of managers, creating immediate safety risks.

WMATA “red tag” procedures require the rail controller, power desk and power employees in the field. This fall, Metrorail added third-party oversight of the rail controller end, which WMATA intended as a temporary check until longer-term power improvements can be implemented.

However, the WMSC found that these critical safety steps were ignored by ROCC and MOC managers and, at ROCC staff’s direction, by those third-party contractors on the noted overnight shifts.

On these shifts, the power desk directed power personnel in the field to close breakers manually. Rail controllers are supposed to close the breakers remotely after it is racked back in, demonstrating that each breaker is properly functioning.

If breakers are closed manually in the field, there are risks for riders, first responders and employees that controllers may not be able to open a breaker remotely to shut off power in an emergency such as smoke, fire or a person on the roadway

After the WMSC identified and escalated this issue, Metrorail has informed us that they are verifying the functionality of the breakers in the field.

Restoring power manually in the field also creates a risk of electric shock for Metrorail employees or contractors who may be on the roadway, since the rail controller would not provide an additional check to ensure that the coast is clear

We appreciate that the General Manager has committed to addressing this serious issue, including again committing at our meeting last week to take steps required to prevent deviations from safety procedures.

That commitment is crucial to ensuring that all employees, at every level, have confidence in the written procedures, and have the necessary direction, training, ability and opportunity needed to execute them.

We look forward to WMATA’s continued work to transform the ROCC as required by the WMSC’s findings and to WMATA’s effort to improve Metrorail’s safety culture as committed to under the Safety Management System approach embodied in WMATA’s Public Transportation Agency Safety Plan

Samarasinghe, on other topics: First, as WMATA has reduced rail service, the WMSC is monitoring service and associated changes. This includes adjustments to the railcar storage and maintenance that is conducted at each yard, with fewer cars needed for service each day.

WMATA now has a cold storage procedure for cars out of service long-term, after we asked for details on these plans. Also, more 6000 Series moving to Greenbelt Yard at reduced speed after special checks. 6000 Series remain out of service following pull-aparts this fall

Samarasinghe: The WMSC is monitoring safety-related aspects of the long-term Blue Line shutdown that Metrorail began last month. We will do the same for the additional shutdowns Metrorail has planned later this year.

Last month, Dr. Mayer testified before the Md General Assembly Transportation & The Environment Subcommittee. We appreciate the committee’s interest in our important safety work and will continue to keep our community and all our local, regional and federal leaders up to date

Samarasinghe: We look forward to working with the FTA on their upcoming triennial audit

Samarasinghe: Finally, I would like to again just highlight the extensive work our staff has been doing while following public health precautions, and to again thank them for their dedication.

Separate from the WMSC’s ongoing Fitness for Duty Audit work, we are working with Metrorail’s Safety Department to add more depth to the fatigue analyses in the investigations.

Samarasinghe: As we will discuss later, we are finalizing our Roadway Maintenance Machine (RMM) Audit, and expect to be able to issue that report within the next two weeks.

We also continue our regular interactions with MWAA & WMATA and oversight of Silver Line Phase 2. Metrorail said last month the most likely opening date is now toward the end of this year, dependent on the timing and progression of construction work, testing and training

Samarasinghe: We do not set this schedule, but service cannot begin on Silver Line Phase 2 until the WMSC concurs that WMATA has properly completed all steps of its safety certification process, including adequate staffing and training for safe operation.

Safety Event Investigations begin with Operations Expert Bruce Walker

Walker: Investigation W-0061 involves a near-miss of a collision near the entrance to the Branch Avenue Yard late on September 3, 2020

The Interlocking Operator gave permission to a Sperry ultrasonic testing vehicle to contact ROCC to access mainline. The Interlocking Operator did not wait for confirmation vehicle left, remotely threw the switches, and told Train 515 at Branch Ave Station to enter the yard

The Interlocking Operator did this based on the Automated Information Management System showing no occupancy in the area approximately 3 minutes after last communication with the Sperry. As a hi-rail vehicle, the Sperry unit does not always shunt the rails to show occupancy

In this case, the AIM data indicates that the vehicle dropped off the display when it entered the interlocking area.

With the ROCC’s ok, the Sperry had begun to move forward when the Interlocking Operator moved the switch. The Sperry operator later reported seeing the switch move just before the Sperry crossed it. The vehicle took that route directly toward Train 515.

The Interlocking Operator had given Train 515 permission to proceed through that same section of track.

A collision was avoided because Train 515 Operator saw the signal turn red, did not move, and reported the situation to the Interlocking Operator. The Sperry operator also recognized the incorrect routing, and reported that the vehicle did not derail

The Sperry vehicle reversed back past the switch, and the Interlocking Operator then realigned the switch so that the vehicle could proceed to the correct mainline track. An ATC inspection found no damage to the interlocking.

This event highlights the need for sufficient training for interlocking operators and other personnel regarding hi-rail vehicles not shunting the rails. It also emphasizes the need for proper radio protocols and response to switch movement under a vehicle

The Interlocking Operator and Sperry vehicle operator have undergone refresher training. Rail Transportation is reviewing the movement process for non-shunting vehicles.

Commissioner Lauby has Bruce Walker explain shunting in more detail (it's the vehicle axles closing the electrical loop so that the automatic system IDs that there is a vehicle there); Hi-rail vehicles do not always shunt/inconsistently shunt

Commissioner Lauby also highlights the movement of the Sperry vehicle after the initial improper movement, and asks why the vehicle moved again/the switch was thrown and continued to be used.
Walker: After vehicle took wrong route, should not have moved without inspection

Commissioner Al Khatib asks for more details on the nature of hi-rail vehicles inconsistently shunting the rails - not all RMMs shunt, they intermittently shunt.
Commissioner Rush emphasizes this is not a unique WMATA issue -- lighter equipment not shunting is industry wide

Investigations Manager Adam Quigley presenting the next report

Quigley: W-0062 relates to an improper Roadway Worker Protection event on 9/9/20 created by conflicting instructions from the Rail Operations Control Center, and miscommunications within the ROCC.

An ATC work crew was granted Exclusive Track Occupancy with local signal control in the Anacostia Interlocking just after 10 a.m. About 20 minutes later, the ROCC identified that it had lost radio communications to the field in that area.

The ROCC button controller incorrectly attempted to adjust signals and switches to get trains holding at red signals through the area.

A third ROCC controller joined the Button and Radio controller at the OPS 3 console and answered a phone call from the Roadway Worker In Charge without coordinating with the Button Controller.

This led to separate communications between:
First, this third controller who decided to join the Ops 3 console and the RWIC
And Second, the Button Controller actually responsible for the area and the ATC work crew member operating the local control panel.

The local control panel operator kept control of the panel, and informed the button controller the work crew remained in the interlocking
The additional controller misunderstood information provided by the RWIC and stated that the work crew was clear of the roadway entirely

This additional controller stated that the work crew had a clearing time of 10:30 a.m. but did not make any effort to have the work crew relinquish local control of the panel. ROCC radio communications were restored at 10:46 a.m.

At 11:01 a.m., the additional controller who had joined OPS 3 desk asked the local control panel operator to adjust signals. When the operator relayed that the work crew was still finishing the inspection, the additional controller stated the work crew was supposed to be clear

WMATA removed the ATC crew from service for post incident testing but did not remove the ROCC staff involved in this event for appropriate testing

The ROCC developed a Lessons Learned document on this event with a focus on communication within the ROCC and with personnel in the field. It also outlines the proper steps to take during radio communications failures

Additional corrective actions that can help mitigate the risk of similar events in the future will be implemented due to the ROCC Audit, which was issued just before this event occurred

Chair Hart asks about additional details regarding ROCC Button Controller v Radio Controller responsibilities & communication process/impact of radio communications loss in this case

Quigley: Would report issue to COMM, meantime use supervisors, landlines/ETS boxes

Quigley: In this case, the ATC crew still had control of the interlocking panel

Adam Quigley presenting the next investigation as well – W-0063 relates to a red signal overrun on the Red Line outside Brentwood Yard on 9/11/20

Quigley: Unbeknownst to the Brentwood Yard interlocking operator, the ROCC had placed an auxiliary call on the switch at the yard entrance which essentially overrides actions by others, such as the interlocking operator, to adjust the position of the switch

Because of this “AUX call”, when the interlocking operator attempted to set a route for a Prime Mover pushing a flat car to enter the yard, the route was not actually set

The Interlocking Operator did not verify that the route was properly set, but stated over the radio to the Equipment Operator and Flagman that the signal was lunar, the switch was aligned for a move into the yard, and that they had permission to proceed.

The flagman did not verify proper rail alignment, and the Equipment Operator and Flagman both acted to proceed based on the radio transmission. Neither identified that the signal remained red

Since the switch remained in the normal position, the Prime Mover and Flatcar continued past the signal on the mainline tracks. Recognizing the incorrect route, the Equipment Operator stopped the unit approximately 200 feet beyond the red signal

The ROCC identified that the prime mover had overrun the red signal. When ROCC contacted the Interlocking Operator, the Interlocking Operator stated that they believed the signal was lunar and the proper route had been set

WMATA failed to remove the interlocking operator from service for post-incident testing, despite the conflicting information the Interlocking Operator provided the ROCC immediately after the event

The Flagman in this event tested positive for a prohibited substance. This may have played a role in the flagman not properly reading the rail or signal.

This event demonstrates a need for comprehensive communication and training, including an understanding of the use of Aux Calls and how to verify that routes are properly set.

Metrorail has committed to improved on-the-job training and checks for interlocking operators, equipment operators and flagmen. The individuals involved in this event received refresher training.

Metrorail also developed a Lessons Learned document with emphasis on movement of Roadway Maintenance Machines (RMMs) when entering Brentwood Yard, and on communication, verification of signals, and verification of rail alignment.

Operations Expert Bruce Walker is presenting investigation W-0064 into a red signal overrun in Greenbelt Yard on 9/15/20

A Train Operator assigned to move railcars in the yard incorrectly repeated back instructions from the Interlocking Operator and followed those incorrect instructions. The Train Operator’s repeat back referred to a signal that does not exist.

The Interlocking Operator attempted to correct the mistaken repeat back, but the train operator did not acknowledge that correction.
This led to the Train Operator moving a four-car 7000-series consist past a red signal and trailing a switch.

The train passed the signal at about 7 mph. The Train Operator stopped about 565 feet past the signal. The Interlocking Operator contacted the Train Operator due to a red signal alarm. This TO was involved in a prior, similar red signal overrun in 2018 in the Alexandria Yard.

Both the Train Operator and the Interlocking Operator stated that there are known radio communications issues in the Greenbelt Yard that have not been addressed by Metrorail. The WMSC recently inspected the Greenbelt Yard and identified this issue as well.

As the WMSC addressed in the ROCC Audit and in findings related to movement with zero speed commands, a repeated failure to address known issues contributes to an environment where problems are not reported.

Rail Transportation developed a “lessons learned” document and committed to radio compliance checks in rail yards.
The Train Operator also underwent yard familiarization training.

Based on this and other events, the WMSC has increased monitoring of rail yard operations as part of our regular inspection and oversight activities.

Commissioner Lauby asks about whether train operators write any instructions/communications down
Walker: WMATA does not require this in their procedures

Bruce Walker: Investigation W-0065 relates to a serious contractor injury in a Yellow and Green Line vent shaft along 7th Street in the middle of the National Mall

The Metrorail contractor fell approximately eight feet to the bottom of a drainage pumping pit while replacing grates in the vent shaft.

The contractor suffered a broken leg and broken nose.

Both the injured contractor and the other member of the contractor work team had fall protection training but did not use any fall protection.

The contractors did not tag grating as secured, so it was not clear which grates were secured.
Metrorail also left the fans on during the work, which made communication difficult over the loud noise.

The investigation shows that Metrorail allowed work to be conducted without required OSHA protections – in this case, fall protection.
Metrorail also did not implement and allowed its contractor to not follow WMATA’s Drug and Alcohol Policy requiring post-incident testing

As a corrective action related to WMATA’s lack of oversight of contractors, WMATA’s Safety Department Construction Oversight team has committed to an increased presence meant to ensure personnel are trained, qualified and using appropriate protections for work being performed

M&M Welding, the company involved in this event, also was directed to develop a Lessons Learned document and to conduct a safety stand-down focused on fall protection.

Chair Hart asks additional question re: testing,
Walker notes WMSC's ongoing Fitness for Duty Audit work

Bruce Walker: Investigation W-0066 involves a customer fatality at Gallery Place-Chinatown Station on 9/14/20

After reaching the lower-level Green/Yellow Line platform, CCTV shows the person was apparently disoriented and unsteady on their feet. At 5:46 a.m., the person fell onto the roadway near where trains toward Branch Ave. enter the station, and appears to have lost consciousness

The person regained consciousness and then staggered to their feet. While appearing to remain disoriented, the customer started collecting their items. At that point - 5:49 a.m. - a Green Line train approached Gallery Place Station at more than 38 mph

111 feet before the platform, the Train Operator put the train’s master controller into emergency braking mode. This coincides with the time forward-facing video indicates it becomes clear that a person is on the tracks ahead.

The train was going approximately 33 miles per hour at the time of the collision.
The train came to a stop 228 feet into the station platform, third rail power was de-energized, and D.C. Fire and EMS responded.

By 6:02 a.m., passengers on the rear cars of the train were walked through bulkhead doors to exit onto the platform from the front three cars.

Bruce Walker: Investigation W-0067 relates to the improper movement of a 7000-series train that had just gone out of service at Metro Center due to door problems.

When the train arrived at Metro Center Station, the doors would not open from the lead car. The Train Operator was instructed to recycle ATC systems, including Automatic Train Protection – or ATP – but this did not resolve the issue.

The Train Operator was directed to go to the fifth car to open the doors. Customers offloaded, and the train went out of service about 14 minutes after the train had arrived at the station

After the Train Operator returned to the lead car of the train and conducted additional troubleshooting steps, the ROCC directed the Train Operator to cut out ATP so that the train would be able to move.

ATP is the system that is meant to protect against speeding and collisions by keeping appropriate train separation. This system includes speed commands based on signals and track occupancy ahead of the train.

With ATP cut out, the train was only allowed to move at 10 miles per hour with explicit permission from the ROCC (an absolute block), unless directed otherwise. This ensures that only that vehicle is in a particular segment of track and the risk of a collision is mitigated.

CCTV, AIM and radio playback show the Train Operator moved toward Federal Triangle without permission from the ROCC, reaching a top speed of nearly 20 miles per hour and going more than 3,000 feet before the stopping upon ROCC identifying this improper movement

The ROCC then granted an absolute block for the short remaining stretch to Federal Triangle Station.

Metrorail replaced the defective door control panel, and the Train Operator received refresher training on SOP 15 – Absolute and Permissive Blocks.

Metrorail has also developed a Lessons Learned document focused on SOP 15 and specific responsibilities for train operators and ROCC personnel when it is necessary to cut out ATP. It is important that WMATA provide recurring training on unusual situations.

Commissioner Lauby asks about the train operator's statement about feeling pressure to move the train

The investigation reports just adopted by the commissioners (0061-0067) are available here: wmsc.gov/oversight/repo…

Corrective Action Plans (CAPs) update: WMATA completed and the WMSC closed 41 CAPs in 2020. There are currently 60 open CAPs, and WMATA is required to propose additional CAPs this month in response to January’s Elevated Structures Audit findings wmsc.gov/wp-content/upl…

Corrective Action Plans are part of the continuous safety improvement process.

CAP status updates are part of our annual reports, which will be published this spring

Among open CAPs, WMATA recently submitted an acceptable revision to C-0037, the CAP in response to our May finding that ROCC management routinely rushes power restoration. This revision adjusts Metrorail’s plan for a permanent improvement to the power restoration process

Under the revision, a rail controller confirms the area is clear/safe to restore power, power desk separately confirms, power desk assistant superintendent verifies those conversations are entered in the track rights system, then power desk closes the breaker

We have also directed Metrorail to provide additional detail on revised plans to the Metrorail CAP related to an NTSB recommendation to provide active warning to roadway workers and train operators of work crews on the tracks.

Audit Updates:
We are finalizing and expect to be able to issue our audit of Metrorail’s Roadway Maintenance Machine maintenance, inspection and training within the next two weeks.

RMMs are the vehicles Metrorail uses for maintenance, track work and other purposes -- other than the railcars that carry riders.

We are also finalizing the draft report for the Automatic Train Control and Signaling Audit, which we expect to transmit to WMATA in coming weeks for their 30-day technical review.

Our Fitness for Duty Audit team completed initial interviews over the last two weeks and is now working on additional document reviews ahead of any follow up sessions in April.

Finally today, resolutions.
First is an updated WMSC ethics policy that is meant to make things clearer with additional detail

Second, a procurement resolution for safety oversight contractor support services

That completes our public meeting for today, but 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

Chair Hart: We expect to hold our next public meeting April 13, 2021. The meeting will again be held remotely, via video conference. We look forward to seeing you then.