Thread by @MetrorailSafety

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

Join us through the 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

Safety message from Emergency Management Specialist Richard David:
-Sumer safety
-Warm up before exercise
-Hydrate, use sunscreen
-Water safety
-Follow appropriate COVID-19 precautions

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 on what’s ahead in the meeting:
-Ongoing safety oversight updates
-Final safety event investigation reports
-CAP and Audit updates
-WMSC FY22 budget

CEO David Mayer: The investigation reports before the Commissioners today cover some of the most significant Metrorail safety events of 2020: the July 7 Silver Spring Derailment, and the two 6000 Series train pull-aparts that occurred on the Red Line last fall.

CEO Mayer: The investigations into these events and related inspection, audit and other oversight work have identified areas in which Metrorail must make important safety improvements to reduce the risk of similar events recurring in the future.

Mayer: We continue to investigate the March 26 runaway train. The post-event debrief with first responders required by the WMSC identified areas for improvement in emergency response and areas that worked well. These are captured and addressed during the investigation process.

Mayer: Our Investigations Program Manager has worked closely with his counterparts in Metrorail’s Safety Department to continually improve investigations and investigation reports.

Mayer: In future meetings, you can expect to see more details related to analysis of probable cause, specific links to corrective actions, and improved data about fatigue.

Mayer: These improvements will take time to implement, so some reports that are being finalized now will have incremental changes until the improvements have been fully implemented.

The point of safety event investigations is to learn from when things go wrong, and to ensure that those lessons learned are actually implemented in a lasting way.

Mayer: The most recent review of these investigation-related corrective actions was completed last month, and WMATA’s Safety Department has followed up with responsible departments on each of those items that were part of that review.

Mayer: WMATA recently made it more difficult for its internal safety investigators to access CCTV recordings required for their work. This is slowing some investigative work and creating challenges for other investigations or reviews.

Mayer: The WMSC also requires direct access to CCTV recordings as specified in the WMSC Compact. The WMSC has attempted to work collaboratively with Metrorail to gain access to the CCTV system to monitor and improve safety, but we may need to take action to require this access.

Mayer: The WMSC published our Automatic Train Control and Signals audit last week with a comprehensive look at the ATC system, which provides critical safety protection for train movement and roadway workers. wmsc.gov/wp-content/upl…

16 findings relate to inadequate safety training, efforts to restore Automatic Train Operation outside of the safety certification process, incomplete maintenance, tools that have not undergone safety reviews, poor coordination, and other gaps wmsc.gov/wp-content/upl…

Metrorail has 45 days from publication of the audit to submit proposed corrective action plans wmsc.gov/wp-content/upl…

Mayer: I would like to highlight the progress that Metrorail has made in some areas following the findings that we issued last month related to radio communication coverage gaps in and around rail yards, and a lack of rules for the movement of vehicles in dark territory.

Mayer: Our work led to some immediate adjustments to improve radio coverage outside the West Falls Church Yard. This is an issue that was only addressed as a result of our active safety oversight.

Mayer: Metrorail is still developing more complete corrective action plans to address these two findings.

Mayer: Our work also continues to drive changes in the Rail Operations Control Center. Our team remains in close contact with the ROCC team regarding ongoing safety changes and procedural improvements.

As Metrorail prepares a new round of long-term shutdowns for capital improvements, these areas remain under our safety oversight throughout the process, as specified in the WMSC Compact.

The WMSC has made clear that all of our Program Standard requirements and WMATA’s safety commitments continue to apply in these long-term shutdown areas, including those requirements related to safety and investigations.

For example, on May 11, a small work cart rolled out of control down the tracks for more than 3,000 feet on the Blue and Silver Lines in Maryland. We gathered additional information related to this event near Addison Road and Capitol Heights.

The WMSC team is reviewing information related to WMATA’s service restoration and construction safety procedures for Arlington Cemetery and Addison Road stations prior to their scheduled reopening.

Following approval last month of the revised Program Standard that goes into effect June 1, WMSC staff have conducted internal orientations, reviews and trainings to ensure we are fully prepared and aligned with the Program Standard's requirements of Metrorail

In accordance with the WMSC conflicts of interest policy, all Commissioners and Alternates have submitted their annual affirmation that they do not have any conflicts of interest and have no role with WMATA.

One new staff member welcome today – Wil Haynes just joined the WMSC as IT Program Manager after more than a decade on Capitol Hill.

Next up: final safety event investigation reports.

Chair Hart: The first two reports being presented today relate to similar 6000 Series train pull-aparts that occurred last fall. Each investigation has its own report.

The reports are being presented together for clarity. Presentation by Operations Expert Bruce Walker, Vehicles Expert Manuel Lopez & Emergency Management Specialist Richard David

Walker: The investigation identified safety issues with the 6000 Series couplers and WMATA’s overhaul process, the operational response, and the emergency response.

Lopez: The direct cause of both pull-aparts were loose fasteners in parts of the coupler assembly. These bolts and other pieces were not properly tightened

Lopez: The root causes that led to this included Metrorail’s lack of and incomplete inspection, maintenance and overhaul procedures; a failure to follow review and approval processes, and a failure to fully learn from prior events to implement systemic changes and reviews.

Lopez: In 2018, before the WMSC had oversight of Metrorail, a similar event occurred involving a 6000 Series train near McLean Station. Unlike these two events, the event in 2018 involved a 6000 series married pair pulling apart.

David: Our investigation and the post-event debriefs that we required Metrorail to hold with first responders identified areas in need of improvement, particularly in relation to the October 9 pull apart.

Walker: I was on the scene of both events and observed the nature of the scene, the emergency response, and the immediate investigative steps.

On October 9th at 12:18 p.m. an outbound Red Line train that had just departed Union Station separated into two parts just after the front of the train exited the tunnel toward NoMa-Gallaudet Station.

The Train Operator reported that Train 108 entered automatic emergency braking, known as Brakes In Emergency. A train operator passing on the adjacent track reported to the ROCC that the train had separated into two sections.

Walker: A few minutes later, the train operator of Train 108 identified that the train display read two cars rather than eight cars. The front two cars were separated from the trailing six.

On November 24th at 1:02 p.m., a Red Line train departing Glenmont separated into two four-car sections as it crossed through the interlocking to proceed toward Wheaton.

The train operator reported brakes in Emergency, and a Rail Supervisor who happened to be on the train walked back and identified that the train had separated. The supervisor immediately reported the separation to the ROCC.

In both events, the 911 calls from the ROCC were not clear about what emergency response was needed and why.

On October 9th, not all Metrorail personnel who were needed at the incident command post reported there.

Partially, this appeared to be due to unclear communication about the location of the command post that Metrorail personnel not as familiar with the area as DC Fire and EMS did not understand.

DC Fire & EMS established the command post on the Hopscotch Bridge - H Street behind Union Station - but not all WMATA personnel understood where that was. Metro Transit Police did not respond to the train location but remained on the periphery of the scene

On November 24th, the emergency response protocols on scene were followed more closely.

On October 9th, Metrorail did not evacuate customers in a timely fashion. Metrorail also did not move the six-car portion of the train back to Union Station in a timely fashion, even though it had been confirmed that it could be moved safely to avoid an evacuation.

Due to both comfort and COVID concerns, customers had opened the side emergency doors of the train as the response dragged on, and there were some customer disputes.

When the evacuation did occur, Metrorail personnel and first responders evacuated the riders through those side emergency doors rather than the bulkhead doors at the ends of the cars as specified in Metrorail procedures.

The ROCC received confirmation that all passengers Oct. 9 were evacuated nearly two hours after the train separated.

The evacuation on November 24th was timely and included the use of the bulkhead doors.

In both evacuations, Warning Strobe and Alarm Devices, or WSADs, were properly placed to verify that power was down prior to and during the evacuation.

However, on October 9, Metrorail did not rack out the breakers as specified in Metrorail procedures to provide an additional layer of protection against power being restored while members of the public were on the roadway.

Following the Oct 9 event, the WMSC identified that Metrorail did not follow chain of custody procedures related to the investigation. Individuals under the Chief Mechanical Officer, Rail reporting structure manipulated fasteners outside of the safety event investigation process.

The WMSC issued a finding on October 20th requiring Metrorail to develop a corrective action plan to ensure the integrity of safety event investigations. Metrorail is in the process of implementing this CAP.

Lopez: I participated in the reviews of the coupler assemblies in each of these events.

In the October 9th event, the buffer tube and gland nut were identified as improperly torqued.

WMATA told the WMSC it would inspect all 6000 Series couplers over the following days, and later said those inspections identified 9 cars with incorrect bolts or other hardware – similar to the 2018 McLean Pull apart – and 4 cars with at least one grand nut thread showing.

Following the November 24 event, the review was even more extensive. Metrorail followed the proper chain of custody for evidence. The coupler head, draft bar, pinch bolt (or clamping bolt) and the bolts holding the guide plate were all improperly torqued.

During the Nov. 24 event review, it became clear that WMATA’s October inspections had only included specific fasteners, and not all fasteners on the couplers.

Further review, including input from the coupler manufacturer Dellner, demonstrated that WMATA’s coupler overhaul and maintenance procedures were incomplete, and that Metrorail did not have special tools required to carry these out.

Metrorail said Dellner never informed Metro that go/no-go gauges were required for the threads on the draft bar and coupler head. Regardless, Metrorail did not have procedures to sufficiently tighten those pieces together during overhaul work.

Metrorail did not have a comprehensive program in place, was not using correct tools or procedures, and did not have oversight of the parts used in the overhaul process.

The 6000 Series cars are out of service indefinitely.

As part of the corrective actions for these pull-aparts, Metrorail is developing new overhaul procedures, procuring the required tools, and determining the best path to examine and properly rebuild the couplers.

Corrective actions also include ensuring proper torque values and adhesives are used and revising inspection procedures.

The WMSC is getting updates from WMATA on their plans for these couplers and other procedures at least every two weeks, and Metrorail plans to provide further specifics on their latest coupler overhaul plans and documentation later this week or early next week.

As specified in our Oct. 1 audit schedule, we are in the midst of our railcar audit - reviewing a broader range of WMATA’s work on railcars. We expect to complete a draft of this report soon, which would lead to issuing this report this summer following WMATA’s technical review

Richard David now to provide some more detail on the emergency preparedness and response aspects of this investigation.

In both events, the calls to 911 dispatchers were not clear on the required response and the nature of the event. This deficiency in the ROCC led to some delay and confusion for the emergency response.

Also contributing, WMATA had not adequately coordinated with jurisdictions to develop a standard response for a train separation event. A standard response for other events defines the types of units such as fire trucks, ambulances and supervisors who respond to a call.

Metro Transit Police did not go to the disabled train on October 9th, which created complications for other WMATA staff on scene managing customers and de-escalating disputes.

Operations departments also suggested that Metro Transit Police could better coordinate with them to help get rail supervisors or other personnel to the scene of an event when rail service is suspended.

The response on Oct. 9 was not fully coordinated through the incident command post on the Hopscotch Bridge. The extended delay in getting customers off the roadway also indicates areas of Metrorail’s emergency preparedness and response that require improvement.

On November 24, there were several aspects of the response that were handled much better.

The train operator on that train and an experienced supervisor who happened to be on board helped the response go smoothly. That supervisor had also been on scene at the Oct. 9 pull-apart

Given the location of the Nov. 24 event, just outside an end-of-line station at Glenmont, the response location was much clearer, and the incident command post was clearly identifiable.

This contributed to improved communication at the incident command post. The Fire Liaison also communicated essential information throughout the event.

However, the Nov 24 event identified concerns with Emergency Tunnel Evacuation Carts (ETECs). The post-event debrief with first responders highlighted areas for improvement in maintenance, inspection and communication about the status.

On scene, the correct evacuation procedures were used to bring riders through the bulkhead doors for the evacuation. There were challenges to setting up the ladder at the end of one car due to the way the coupler remained attached.

Metrorail and Montgomery County Fire and Rescue Services personnel were able to make adjustments to the positioning of the ladders to make the ladders work.

Comm. Lauby: 90+ minute evacuation needs this focused review; communication with passengers on the trains are crucial to let them know what was going on
Quigley: In about 15-20 minutes, supervisors were on scene - second half customers update; but for next hour, no full plan

Quigley: WMATA corrective actions include changes so that within about 10 minutes of troubleshooting, will take more immediate action for customers to avoid bigger issues

Comm. Lauby asking about the differences in couplers across car fleets

Lopez: Issue here appears to be how 6000 Series coupler overhaul process was carried out - tools, documentation, training

Chair Hart also emphasizes importance of clear communication and response with & for passengers

Next and final investigation presentation for the day is by Investigation Program Manager Adam Quigley

Investigation W-0081 involves the July 7, 2020 derailment just outside of Silver Spring Station. Red Line Train 108, headed northbound toward Glenmont, derailed at 11:20 a.m.

The Train Operator moved the train past a red signal at the end of the platform seconds after the Rail Operations Control Center sent a command to realign the switch to a normal, straight-through position. The train operator did not have permission to pass the red signal.

The switch moved under the train. The first car followed the original position of the switch and entered the pocket track toward Train 880. The second car derailed.

The Train Operator was able to pass the red signal without any redundant protection because the train had lost speed commands as it entered the station platform. The train operator activated stop and proceed mode to service the station.

After closing the doors, the train operator returned to the console and immediately proceeded without verifying the signal aspect or rail alignment. WMATA’s stop and proceed software does not reset until speed commands return or the train exceeds 15 mph.

The train operator had made the same trip several times earlier in the day and had experienced a lunar signal at this location each time.

The ROCC controller began the computer clicks required to realign the switch at 11:20 and 10 seconds. The train departed the platform about 2 seconds later, and the ROCC controller completed and sent that switch command two seconds after that.

The switch began to move approximately six seconds after the ROCC command was sent. The switch completed the move 5 to 6 seconds after it began to throw.

After the train derailed, all cars remained upright, but the first car was misaligned from the second car, blocking the bulkhead doors between the two cars and preventing their use to evacuate the one passenger on the lead car.

The riders in the rear 7 cars were able to walk back through the train and evacuate directly onto the platform.

Vehicle systems data show that the train had accelerated to 15 miles per hour just before the derailment. This triggered automatic braking since the train remained in stop and proceed mode.

The train was moving about 11.6 miles per hour at the time of the derailment as the switch was throwing under the train.

The point of derailment was 83 feet from the signal, and the point for rest was 118 feet from the signal. The lead car stopped 240 feet from the end of the platform and did not contact Train 880.

The operator of Train 880 reported the derailment over the radio, and the operator of Train 108 then acknowledged that the train had derailed.

The ROCC Controller immediately attempted to respond to these reports, however the controller microphone did not work. Ambient recordings in the ROCC demonstrate that proper attempts were made to transmit, but radio recordings show that those communications did not transmit.

After the WMSC identified this issue, the investigation found that the microphone problem had been identified on the prior ROCC shift, but that Metrorail did not send anyone to fix the issue

After the derailment, the microphone was replaced, but that replacement microphone also did not work and had to be replaced again

The controller had a heavy workload already that day due to flooding between Cleveland Park and Woodley Park stations, and was not able to immediately restore the switch to its normal position when Train 880 cleared the switch.

As the controller commanded the switch to return to the normal position, Train 108 departed Silver Spring Station. Had Train 108 not derailed, it could have collided head on with Train 880.

During the emergency response, Controllers repeatedly received conflicting direction from management regarding service patterns and response. This was one part of Metrorail’s failure to follow incident management protocols.

Reviews of recordings and other data demonstrate that these controllers handled the post-derailment response related to ongoing operations of other trains outside of the incident area extremely well.

During the derailment response, upper-level management pressed the controllers to resume normal service in the Woodley Park area, where trains were single tracking by that point in the morning.

The controllers coordinated this to the best of their abilities, but this detracted from their focus on the derailment response.

In addition to the ROCC Controller communications failures, the Fire Liaison also could not communicate on the radio with first responders in the field during this event.

Metrorail was using Office of Emergency Management employees to fill the role at the time but had not provided training on how to do that. Regular uniformed Fire Liaison staffing resumed a few weeks later.

Metrorail also did not have a backup phone that patches into the first responder radio system available in the ROCC at the time. The post-event debrief suggested this phone was left in the other ROCC facility during a changeover

At the scene of the event, Metrorail personnel did not report to incident command or a staging area, and instead crowded the platform.

This event occurred during the WMSC’s ROCC Audit work wmsc.gov/wp-content/upl…

The WMSC’s ROCC-related findings require corrective actions that address issues identified here, including fixing dysfunction in the ROCC during emergencies, repeated failures to address safety issues, inconsistent training, and limited emergency drill experience

Specific corrective actions in this investigation include a review of automatic signals, microphone upgrades and communications maintenance schedules, changes to emergency management in the ROCC, and a commitment to improved train operator check rides and on the job training.

Next up is Corrective Action Plan updates from WMSC Business Process Specialist Lahiru Karunaratne

The WMSC continues to work hard to review, consider, and address the sizable number of WMATA submissions of CAP deliverables, extension requests and closure requests.

WMATA submitted a required CAP proposal related to gaps in the Intrusion Detection Warning system on time. The WMSC provided comments requiring revisions early last week. This finding followed a train collision with a fence near Union Station on Feb. 11

Separately, Metrorail is required to submit proposed CAPs related to the findings on radio communication deficiencies in rail yards and vehicle movement in non-signalized territory in a few weeks.

Those findings were based on WMSC inspections and other oversight work that confirmed significant radio communications challenges and procedural gaps in rail yards that pose safety risks related to vehicle and personnel movement.

This follows separate issues identified in the RMM Audit published this winter.

CAPs related to the ATC Audit that was published last week are due by late June.

COO Samarasinghe: We issued our Automatic Train Control & Signaling Audit to WMATA last week.
As with each of our audits, it is based on extensive interviews, data reviews and document reviews. We conducted this work in late 2020 and winter 2021. wmsc.gov/wp-content/upl…

The 16 findings in this audit include:
Metrorail has not adequately trained ATC employees on safety procedures.
Metrorail has continued efforts to return to Automatic Train Operation without following its safety certification procedures
wmsc.gov/wp-content/upl…

Metrorail is not conducting all inspections and maintenance required by its ATC manuals
Metrorail allows employees to use tools that have not gone through any safety review or approval process
wmsc.gov/wp-content/upl…

WMATA does not have a standardized process to prioritize and advance ATC capital projects
Metrorail does not have documented ATC software standards
There are training, planning, parts and procurement deficiencies
wmsc.gov/wp-content/upl…

Samarasinghe: Metrorail’s history in this area over the last 15 years demonstrates the importance of vigilance in this area. The train control system at Metrorail is vital to the safe movement of all rail traffic on the Metrorail system.

Metrorail has 45 days from the issuance of the audit to submit proposed CAPs. The WMSC will review these proposals carefully once they are submitted.

We continue our work on two other audits.
The Fitness for Duty Audit and Railcar, or Revenue Vehicle Audit are nearing completion of draft reports.

Our Traction Power audit is getting underway by reviewing documents that have been provided by WMATA. Interviews for this audit are scheduled for next month.

On to resolutions and other action – first item is the WMSC’s FY22 budget

Secretary-Treasurer Debra Farrar-Dyke now presenting: Finance and Operations reviewed this final budget plan April 29 and recommends approval

Farrar-Dyke: This is the conclusion of a required months-long process that included development and distribution of the draft work plan and budget last fall, review, input and sign-off from the jurisdictions, and the process now culminates in today’s final approval vote.

This Fiscal Year 2022 budget covers July 1, 2021 to June 30, 2022

CEO Mayer: We worked extremely hard to make sure that next fiscal year’s budget is right sized for our current operations.

Mayer: This hard work led to a $600,000 lower budget for the coming fiscal year when compared to our current budget. This is intended to assist the jurisdictions in this challenging time while meeting our staffing and oversight needs.

Mayer: To be clear, we do expect that additional needs may arise in future years based on areas that we identify in our continuous improvement process, but this budget allows us to continue our robust safety oversight program with the funding available today.

This budget was completed following all provisions in the Master Funding Agreement in coordination with Maryland, Virginia and the District of Columbia.

Mayer: The work plan sets forth the WMSC’s financial plan for our upcoming fiscal year, which starts on July 1. It establishes an overall budget of just over $5 million for the WMSC, of which the largest share goes to pay salaries and benefits for our staff.

The commissioners approve the FY22 budget

Next resolution – with Program Standard revisions and consolidation effective shortly, re-adopting the dispute resolution process

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 June 29, 2021. We look forward to seeing you then.