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

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

Safety message of the day:
-Use 3 points of contact on escalators/stairs: hold handrail & stay in control
-Stay back from platform edge unless boarding a stopped train
- Never enter the tracks as a rider. If you drop something, ask a Metro employee for help

Have a safe #July4

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 oversight updates
-Final safety event investigation reports
-CAP and Audit updates
-Procurement resolution

CEO David Mayer has several items to report

CEO Mayer: twice this month, the WMSC has informed WMATA of safety events occurring in the Metrorail system that WMATA as an organization was not aware of.

After the WMSC informed WMATA of the need to properly identify, report and investigate these events, Metrorail belatedly sent notifications to the WMSC.

This is another example of the importance of our independent safety oversight and the significant access to Metrorail data, information and systems that comes with it, because each properly investigated event provides a path to reducing the risk of a similar event in the future.

In the first event, on June 11, the WMSC’s regular monitoring identified that a Metrorail customer had posted an image on Twitter from a train with doors open on the wrong side at Rhode Island Avenue Station.

Although this information was public, and other aspects of a door issue related to a possible emergency release handle activation were reported over the radio, Metrorail did not identify this as a safety event.

The WMSC however acted quickly to gather additional information, including witness statements, and ensured that as much data as possible was collected for review.

After the WMSC notified Metrorail’s Safety Department of these details, they worked with us on that data collection and analysis.

Preliminarily, it appears that the train showed an external emergency door handle fault beginning at Fort Totten Station that did not impede train movement.

When the train was at Rhode Island Avenue Station, the Train Operator walked back through the train in an attempt to address door issues possibly related to the fault, and used a panel known as a Hostler panel at the rear of a car to open the doors.

Because the panel on the car faced the opposite way the train was travelling, using the “left side” button actually opened the doors on the right side - the side facing away from the platform. The train operator did not report this wrong-side door opening.

We expect more details and any updates or corrections to that preliminary information based on the remainder of the investigation.

The second recent event that the WMSC notified WMATA of involves Improper Roadway Worker Protection on the Red Line between Grosvenor-Strathmore and Medical Center stations on June 23

A Train Operator suddenly came upon a work crew that appears to have exited a drainage pumping station room without proper protections in place.

The Train Operator reported these personnel on the roadway to the ROCC over the radio, however Metrorail did not take any action and did not report this significant safety event to the WMSC.

The WMSC identified this event, reviewed additional radio traffic and other information, and required Metrorail to properly report and investigate this event.

Metrorail submitted the initial formal notification to the WMSC approximately 10 hours after the safety event occurred.

Preliminarily, it appears that a work crew was dropped off by a Red Line train, entered a room for work, but then exited the room without protection to get improved radio connectivity.

The next Red Line train passing through the area came within about 100 feet of where this crew had been on the catwalk as the train approached.

By the time the train stopped after the operator applied emergency braking, the crew had fled back into the room.

We expect more details and any adjustments to this preliminary information based on the remainder of the investigation.

In relation to a number of investigations, CEO Mayer providing an update on some WMATA corrective actions tied to Red Signal Overruns and Improper Roadway Worker Protection

Last week, WMATA issued a safety alert related to the role and responsibilities of Roadway Workers-In-Charge or RWIC. This is the person who ensures that all necessary protection is in place in their work area

Metrorail is also increasing internal oversight of roadway work zones.

Metrorail is developing plans to provide additional instruction on the proper use of the General Orders and Track Rights System (GOTRS) used to request track time and schedule work zones

Further, Metrorail is continuing its longer-term plans over the course of this year to revise Roadway Worker Protection rules and training.

Among these changes, the Safety Department has committed to sharing details of safety event investigations with the training department when investigators identify training as a factor, and with other departments to better develop corrective actions.

In relation to red signal overruns, after a spike at the end of last year, there has been a significant drop off since the start of this year, following a safety-stand down.

The one overrun that has occurred since the standdown was linked to poor radio communication in a rail yard, which the WMSC issued a finding on this spring.

Metrorail has also increased check rides, conducted research and assessments, and restored refresher training for new Train Operators.

WMSC staff are also continuing to monitor Metrorail’s vehicle rehabilitations.

This week, our staff are observing 6000 Series coupler overhaul training being provided to Metrorail by the couplers’ original equipment manufacturer.

This is an early step in Metrorail’s process to determine how to safely restore the 6000 Series to service following the two-train pull-aparts last fall.

On June 24, the WMSC’s commissioners denied a petition from WMATA related to the WMSC’s Fitness for Duty Audit, requesting that the WMSC reconsider a portion of its directive to WMATA to submit records necessary for the audit.

WMATA’s request was to withhold drug and alcohol testing information related to Metro Transit Police Department employees. This is contrary to federal regulations and WMSC requirements.

MTPD officers are Metrorail employees designated by WMATA as responsible for safety, and they serve as first responders who play a key role in the safety of passengers, other first responders, and workers.

FTA regulations require the release of these drug and alcohol testing records to the WMSC in a number of circumstances, including triennial audits.

WMATA submitted its petition months after initial documents for this audit were due.

WMSC staff are now finalizing the draft of this Fitness for Duty Audit.

The audit timing was specified on the schedule provided to WMATA last October, communicated in the notification letter for this audit, and then extended to allow WMATA additional time to provide documents that Metrorail only has in paper form.

The commissioners also approved a Program Standard change to reflect the Metrorail Safety Department’s new Incident Management Official, and the role that individual can play in ensuring safety events are properly documented and ensuring that perishable evidence is not lost

This adjustment to the Program Standard allows Metrorail’s IMO in specific cases to gather information and determine when it is acceptable to release the scene under Metrorail policies and under the requirements set in our Program Standard.

In other cases, mainly serious events that result in detailed investigations that often rely on perishable evidence, Metrorail will continue to contact the WMSC to obtain our approval to release the scene before moving the affected equipment and restoring service.

Separately, the WMSC Finance and Operations Committee met last week. Following those discussions, the WMSC has exercised a contract option to initiate our second independent financial audit. The work will get underway this week, with the WMSC’s fiscal year set to end tomorrow.

Also on the business front, we are proud to report that we are exceeding our Disadvantaged Business Enterprise (DBE) goal of 4.3 percent.

As we recently reported to the FTA on our last semiannual report on our DBE goal, we achieved 9.13 percent for the period ending this month, and we achieved 17.13 percent in December 2020, (the prior semiannual report).

This demonstrates our continued commitment and focus in this area.

Safety Event investigations are up next. Two reports are on the consent agenda.

The first report being presented is from Dec. 13, 2020. Presentation by WMSC Emergency Management Specialist Richard David and Traction Power Expert Tino Sahoo

W-0084 involves a safety event related to losses of third rail power and eventual customer evacuations without the safety precautions that are required by Metrorail procedures.

On Sunday, December 13, 2020, breakers in Fort Totten Tie-Breaker Station #2 and the Georgia Ave.-Petworth Traction Power Substation were opening and closing repeatedly and could not be restored remotely.

In the eventual evacuation, Metro Transit Police Department (MTPD) personnel, who WMATA has designated as responsible for customer safety in emergencies, ignored safety procedures and evacuated customers without placing Warning Strobe and Alarm Devices (WSADs) on the roadway.

MTPD and Metrorail also did not follow incident command protocols. Due to MTPD not using these safety devices, D.C. Fire and EMS did not assist with the evacuation.

The initial power issues occurred after power work that WMATA had been conducting in the area. The Tie-Breaker Station had been restored to service the day before this event with new Secheron systems.

The Georgia Ave.-Petworth Traction Power Substation had a solid-state electromechanical DC Overcurrent Protective relay that failed causing intermittent tripping and closing. This and another relay are more than 25 years old, about twice their expected life.

When breaker 32 tripped, that automatically tripped breaker 36, and shifted the load to Tie Breaker Station #2’s Breaker 64. That backup did not hold up because a protective function on the newly activated DC feeder breakers was not set at the correct sensitivity.

In the Tie-Breaker Station with new gear, the Inverse Definite Minimum Time Overcurrent protection had been set too low - to the level of Metrorail’s old VG Control relays. However, the new Secheron switchgear requires a different setting.

This setting sets the level and duration of current that will trip the breakers as a protective measure.
Since this setting was incorrect, it led to Breaker 64 tripping when it should not have, de-energizing the third rail.

A Load Measuring relay also lost its negative reference, preventing the remote and manual closing of the breakers.

After this event, this reclosing relay was jumpered out of the circuit to temporarily be able to close circuit breaker 32 and then later replaced. The failed DC overcurrent relay was replaced as well.

The IDTM relay protective function was temporarily disabled on all the DC feeder breakers in Fort Totten Tie-Breaker #2 to prevent nuisance tripping. These measures allowed for the third rail to be energized and the resumption of revenue service.

The relay manufacturer Secheron has provided new settings for the IDTM relay protective function. These settings will be tested offline via the statistical mode on the relays.

This will allow WMATA to see how these settings react to actual revenue service, but only in the background, without making the setting active in a way that could inadvertently trip a breaker. After the data is reviewed, Metrorail will be able to make revised settings active.

In the meantime, several other protective functions remain in place.

At approximately 7:30 p.m. on Dec. 13, about an hour and a half before the main event at issue here, the ROCC had de-energized third rail power on Track 2 between Fort Totten and Georgia Ave-Petworth stations for a cat reported on the tracks.

That event began to wrap up just before a scheduled 9 p.m. Rail Operations Control Center shift from the downtown facility at Metrorail headquarters to the main facility at the Carmen Turner Facility in Maryland.

The ROCC downtown attempted to restore power at approximately 8:40 p.m., however two breakers in the Georgia Ave.-Petworth Traction Power Substation would not close.

At 8:44 p.m., while southbound Green Line Train 501 was at the platform at Fort Totten Station, third rail power de-energized for approximately 5 seconds. This had occurred several times as other trains were leaving the station platform.

A northbound train entered Fort Totten Station. As that train departed at 8:47 p.m., power again de-energized on the southbound track for 55 seconds.

The ROCC dispatched a traction power crew to the Georgia Ave-Petworth Traction Power Substation.

At 8:57 p.m., Train 502 departed toward Georgia Ave.-Petworth. A few seconds later, power de-energized and the train stopped. Power briefly re-energized as another southbound Yellow Line train approached Fort Totten Station.

Power then de-energized again at 8:58 p.m., when two breakers tripped uncommanded in Fort Totten Tie-Breaker Station #2.

Both Train 502 and Train 308 stopped due to the loss of power.

The operator of Train 308 radioed to the ROCC that their train had no dynamic braking and reduced propulsion. The controller instructed the operator to proceed in P3 power mode.

The operator of Train 502 reported that their train was slowly coming to a stop on emergency lighting, with no third rail power. The rail controller asked the operator of Train 502 to operate in P3 power mode, but the operator reiterated that the train had no power.

ROCC controllers attempted to remotely close the breakers to restore power, but that did not work.

At 9 p.m., a Rail Transportation Supervisor at Fort Totten Station looked down the tracks toward Train 308 just outside the station.

At 9:16 p.m., the ROCC Assistant Superintendent provided the first notification to Metro Transit Police.

At 9:24 p.m., two MTPD employees went beyond the handrail at Fort Totten Station without required Roadway Worker Protection to walk to Train 308.

At approximately 9:36 p.m., two other MTPD employees went beyond the end gate without required Roadway Worker Protection.

Metrorail did not immediately call for D.C. Fire and EMS assistance

Communication was further complicated by a ROCC shift changeover between the backup facility downtown and the main facility in Landover, and an incomplete handoff between the outgoing and incoming Fire Liaison.

MTPD staff also participated in a non-work-related conversation with the Fire Liaison during the event, and the handoffs were further complicated by the event involving the cat on the roadway that disrupted the typical handoff process.

The challenge relates to the move between facilities. The new Incident Management Official now being implemented presents an opportunity to improve this transition.

At 9:32 p.m., a Rail Operations Information Center Specialist asked their assistant superintendent whether a 911 call should be made. That assistant superintendent asked an MTPD dispatcher if DC Fire and EMS was needed, and MTPD said they had not requested it.

At 9:38 p.m., the outgoing Maintenance Operations Center Assistant Superintendent stated that a determination had been made to evacuate a train, and that the ROCC Assistant Superintendent had stated that the ROIC specialist had called for DC Fire and EMS assistance.

At 9:38 p.m., D.C.’s Office of Unified Communications dispatched firefighters to Fort Totten Station for a report of a train stuck on the tracks.

At 9:40 p.m., Traction Power personnel informed MOC radio communication was bad in the Tie-Breaker Station. MOC instructed that employee to notify other personnel not to energize the breakers. MTPD also later informed MOC that their radios also could not transmit in the tunnels.

At 9:47 p.m., D.C. Fire and EMS stated they had established a unified command with MTPD. MTPD later made decisions outside of that command process.

At approximately 9:55 p.m., MTPD brought customers from Train 308 onto the roadway without protective equipment required by Metrorail procedures. MTPD did not place Warning Strobe and Alarm Devices – WSADs – that provide notice if third rail power is inadvertently restored.

The seven customers proceeded onto the roadway, then onto the catwalk into Fort Totten Station.

At this point, Metrorail had not fully dispatched MTPD or requested D.C. Fire and EMS response to Georgia Ave.-Petworth, which was closer to the other stranded train.

MTPD and DC Fire and EMS at Fort Totten determined that they would move the existing responders to Georgia Ave.-Petworth. Station. They arrived outside the station at approximately 10:16 pm.

D.C. Fire and EMS responders brought their WSAD into the station, and an OEM employee who arrived later also brought an additional WSAD.

However, MTPD did not place this safety equipment on the roadway. D.C. Fire and EMS personnel correctly indicated that this safety equipment is required by Metrorail procedures.

Because MTPD did not follow these safety procedures, D.C. Fire and EMS remained on the platform and did not enter the roadway.

MTPD personnel and a Rail Transportation Supervisor entered the roadway without this safety equipment and assisted with a customer evacuation.

The 13 customers who had been stranded on the train for approximately an hour and 45 minutes reached the Georgia Avenue station platform at approximately 10:42 p.m.

Following this event, Metrorail reviewed the Fire Liaison turnover process, and the regional Fire Liaison Program Manager reviewed handoff procedures between locations.

In this event, the on-duty Fire Liaison left the downtown headquarters for the Maryland ROCC facility when it appeared the cat on the roadway event had wrapped up.

A backup Fire Liaison covering that time was at the downtown headquarters, but due to a lack of space, he was placed in a room adjacent the ROCC, and Metrorail personnel did not clearly communicate with him.

MTPD committed to developing an incident response and incident command checklist.

The WMSC has observed and communicated similar deficiencies in MTPD response in connection with the response to the Oct. 9, 2020 train pull-apart near Union Station and, preliminarily, in the response to a Mar. 26, 2021 disabled train that later resulted in a runaway train event.

This event also suggests that MTPD personnel do not fully understand operations in the rail system, including the need to hot stick and confirm power is down and to coordinate with the ROCC to ensure proper roadway worker protection is in place.

MTPD did not follow safety rules meant to protect customers, workers and first responders. This suggests MTPD may need more specific, ongoing training on operating safely in the rail system and the rail system’s characteristics.

In response to those events and prior WMSC findings, WMATA developing additional emergency response procedures and protocols that Metrorail intends to limit the time customers may be stuck on a train and to improve the urgency of emergency response

MTPD and TRPM reported communications issues so significant, cell phones were used rather than radios to provide updates during the event, yet Metrorail’s Communication Section closed out the work order by stating that several individuals said there were no issues.

This does not reflect the systematic safety approach WMATA has committed to under its agency safety plan that requires the full evaluation and mitigation of hazards.

These communications issues also led to employees, including an MTPD Sergeant, not having all required information. This created significant challenges even with the evacuation of a very small number of customers.

TRPM disabled and later, following both additional analysis and information from the manufacturer, adjusted the protective settings for the new switchgear

This event also demonstrates the hazards posed by obstructions and narrowed pathways on the emergency catwalk.

The blocked paths (by materials or by built-in items) contributed to the need for MTPD officers and customers to be on the roadway, and could impede emergency egress in other circumstances

MTPD employees who contributed to this improper evacuation without required safety equipment were not tested as required by WMATA’s Drug and Alcohol Policy.

Chair Hart: This report is very troubling

Comm. Lauby: How can MTPD who responds to these emergencies ignore requirements so much DCFEMS did not enter roadway due to potential danger, that drug and alcohol testing was not conducted as required?

Staff: WMSC continuing to review/gather info on MTPD, upcoming audit as well

Comm Lauby: very important incident even though did not result in property damage or injuries to passengers or employees, very important because of all the different things that seemed to go wrong

Comimssioners vote to send this report back to WMATA for further responses/action

Remaining reports are being presented by Investigation Program Manager Adam Quigley

W-0085 involves Improper Roadway Protection near Fort Totten Station on December 12, 2020.

Just prior to a ROCC Controller shift change, an outgoing controller properly granted Foul Time protection to a Traction Power Maintenance crew that had just completed their primary overnight work.

The crew needed Foul Time to move to a different area to restore power ahead of the system’s opening for Saturday morning revenue service.

Foul Time protection is meant to ensure that no rail vehicle moves through the work area while the work crew is on the roadway.

However, while the work crew was still on the roadway, a different rail controller who had taken over the desk gave permission to the equipment operator of a prime mover to move through the area where the work crew had foul time protection on the Green and Yellow Line tracks.

The work crew fled the roadway from the interlocking when they saw the Prime Mover’s lights moving toward them. The crew entered the Tie-Breaker Station room. The equipment operator stopped the Prime Mover and checked with the work crew for any injuries.

The investigation demonstrates that the incoming controller removed all protections for the work crew on the roadway after taking over the desk, despite a turnover that included the fact that this work crew remained on the roadway.

This event highlights the importance of training and ongoing operational oversight to ensuring safety. Metrorail may also consider specific processes to ensure that incoming controllers review all aspects of their territory and maintain full situational awareness.

The controller who incorrectly provided an absolute block through a work zone was retrained.

The ROCC developed and distributed a lessons learned document based on this and other instances of improper roadway worker protection.
ROCC management also issued a memorandum instructing incoming controllers to establish radio communications with any personnel under Foul Time.

Chair Hart asks several questions related to how employees recieve and sign off on lessons learned documents and memoranda

Comm. Lauby asks details about shift handover

Comm. Farrar-Dyke asks details of the lessons learned, emphasis of outcome

W-0086 involves Improper Vehicle Movement on Red Line on December 30, 2020.

A Rail Operations Control Center controller improperly allowed a train in revenue service toward Glenmont Station to proceed toward a maintenance vehicle that was waiting to enter the Brentwood Rail Yard.

Prime Mover 46 had been given an absolute block. That means that no other vehicles are supposed to be in that segment of track. This type of block is intended to protect against collisions.

The Prime Mover had initially been heading to Glenmont Rail Yard following overnight work, but at 5 a.m. the ROCC directed the Equipment Operator to instead exit the mainline tracks into the Brentwood Rail Yard to limit impacts on revenue service as the system opened to riders.

The Prime Mover arrived at the Brentwood Yard entrance at approximately 5:20 a.m.

Five minutes later, a ROCC controller who had just come on duty removed a protective measure known as a “prohibit exit” from signal B03-04, and set a lunar, or proceed signal, for Train 115 to enter NoMa-Gallaudet University Station.

However, Prime Mover 46 was still stopped just beyond the station waiting to enter Brentwood Yard.

The vehicles came within about 1,200 feet of each other without required safety protections in place.

Metrorail retrained the controller involved in this event.

Metrorail has since begun to roll out its required Safety Management System (SMS) specified in its Public Transportation Agency Safety Plan (PTASP) in the ROCC since this event occurred

A complete SMS approach includes an effective safety culture where everyone from frontline workers through supervisors and managers to the top of the organization share in a commitment to safety and continuous improvement.

This rollout and Metrorail’s other required actions tied to the WMSC’s ROCC’s findings are intended to improve these areas where Metrorail has historically had deficiencies.

W-0087 involves improper door operation at Capitol Heights Station on December 29th, 2020.

In this event, a Rail Transportation Supervisor had improperly entered the operating cab of the final train of the evening toward Largo Town Center, outside of Metrorail rules and procedures.

For several stops, the supervisor operated the doors of the train while the Train Operator only handled train movement, which is contrary to Metrorail rules and procedures.

At Capitol Heights Station, the Supervisor attempted to open the doors prior to the train being properly berthed.

The Train Operator then hit the “Ok” button, and the supervisor opened the doors on the correct side of the train, while the Train Operator opened the doors on the incorrect side of the train

While both said they heard two “doors opening” chimes in close proximity, they did not believe anything was wrong since the supervisor looked out the platform side window and saw that doors were open on the platform side.

Only after the supervisor had closed the platform side doors and the train would not move did they identify that the doors had also opened on the wrong side.

Neither the Train Operator nor the Supervisor immediately reported this improper door operation to the Rail Operations Control Center. A ground walk around required by Metrorail safety procedures was not performed.

The Station Manager approached the operating cab to inform the Train Operator and Supervisor of door operation issues, and the Station Manager reported the improper door operation to the ROCC Assistant Superintendent.

When the ROCC contacted the RTRA Supervisor, the supervisor acknowledged being in the operating cab during the event and that the doors had opened on both sides of the train.

Metrorail did not remove the supervisor from service for post-event drug and alcohol testing as required by Metrorail policy.

In conjunction with responses to other events and WMSC actions, Metrorail is planning to improve on-the-job training for operators, ride check processes and recurring qualification requirements.

Rail Transportation produced a lessons learned document discussing this event, associated hazards, safety rules and SOPs and the importance of supervisors notifying the ROCC before riding in an operating cab.

Commissioners have several questions related to operating rules/supervisor in cab, drug & alcohol testing

Drug and Alcohol testing is part of the WMSC's upcoming Fitness for Duty audit

W-0088 involves an improper door operation at Franconia-Springfield Station on December 16, 2020

The operator of an eight-car Blue Line train stopped and opened the train’s doors with the trailing two cars still off the platform.

The Train Operator stopped the train near the six-car marker rather than the eight-car marker, and stated they were not aware that the 3000-series train was an eight-car consist

The Terminal Supervisor attempted to contact the Train Operator when the train stopped, but the Train Operator did not respond until after they had opened the doors.

Metrorail has required all trains to stop only at the eight-car marker as part of a rules-based effort to avoid this type of event.

The Train Operator and Terminal Supervisor performed a ground walk around and did not identify any damage, injuries, or customers on the roadway.

This Train Operator had approximately one year of experience.

In an investigative interview, the Train Operator said that they thought stopping at the six-car marker was acceptable since they believed they had a six-car consist and stopping short of the end of the platform would save them time for a needed personal relief break.

The operator had been operating a six-car train earlier in the morning on the previous trip to Largo Town Center and was directed on arrival to Largo to quickly move to this eight-car train that was ready to depart.

Metrorail does not have pre-trip inspection requirements for operators taking over a new train and allows operators to be on the train as few as two minutes before departure.

The Train Operator said that while operating that new train back to Franconia-Springfield they identified at Pentagon Station that they would require a personal relief break, but that they thought they could make it to Franconia-Springfield.

The Train Operator did not request this relief break from the ROCC at any point. By the time of arrival at Franconia-Springfield, this break was urgently needed.

The train operator underwent retraining, and Metrorail’s Rail Transportation department developed and circulated a lessons learned document related to this and other improper door operation events.

Chair Hart confirms that there is information in the operating cab that shows the length of the train

Comm Lauby emphasizes that WMATA rules require all trains stop at 8 car marker (unless some unusual circumstance where instructed to stop at different location)

W-0089 involves a red signal overrun at Eastern Market Station on December 15, 2020.
This red signal overrun occurred just prior to the start of revenue service.

The Train Operator of an employee train used to bring station managers to their posts reversed ends at Eastern Market and then moved the train, without authorization, back in the direction of Largo Town Center.

The Train Operator stopped the train approximately 9 feet beyond red signal D06-02 at the Eastern Market Interlocking.

When the train operator began moving, they radioed the ROCC controller that they had a lunar, or proceed, signal and were on the move. When the controller asked that the message be repeated, the train operator said to disregard the message.

In an investigative interview, the operator said they said disregard after noticing the signal was red and applying the brakes.

Approximately 30 seconds later, the ROCC controller asked the Train Operator for their location, and the operator said they were holding at the red signal. The Train Operator did not clearly respond when asked if they were properly berthed at Eastern Market Station.

Several minutes after that, a different ROCC employee told the controller to look at their alarms that showed the train had passed a red signal. When then asked directly, the train operator acknowledged the train had passed the red signal and was in the interlocking.

Vehicle downloads collected during the investigation show the train had reached a top speed of 7 mph and moved 171 feet before stopping 9 feet beyond the red signal near the end of the station platform.

Due to the location of the train in the interlocking, rail service was suspended in the area for approximately 30 minutes.

The operator had performed the same task several days in a row, and had always had a lunar, or proceed, signal at this location.

On this day though, the signal was red to protect maintenance vehicles that were moving in the area after completing overnight work.

The Train Operator had only been certified for approximately one month at the time of this event, following a long layoff between classroom training and practical training.

This is one of several events that Metrorail identified involving operators with less than three years of experience.

Since this was a 3000 Series train, there is no inward or outward facing video available to further determine the operator’s actions and to identify additional possible safety improvements.

Since a Safety Standdown that Metrorail conducted this winter in response to this and several other red signal overrun events, Metrorail has reported one red signal overrun, suggesting that this training was effective

In relation to this specific event, the train operator was retrained and four cars of this consist were repaired to address Vehicle Monitoring System failures.

This is another event that demonstrates the benefits of ensuring stop and proceed mode or other redundant protections are in place to reduce the risk of unauthorized train movement with zero speed commands and past red signals.

W-0090 involves a red signal overrun in the New Carrollton Rail Yard on December 16, 2020.

A Train Operator of an eight-car 7000 Series train incorrectly repeated back movement instructions to the Interlocking Operator, who affirmed the incorrect instructions.

This led to the operator moving the train past a red signal that the Interlocking Operator had not granted permission to pass.

The initial instructions provided an absolute block from New Carrollton Station to Signal D99-54, with permission to pass red signal D99-50.
The Train Operator’s repeat back, which was not word for word, did not match the Interlocking Operator’s instruction.

Instead, the repeat back stated that the operator had heard permission to pass red signals at both signals D99-50 and D99-54.

The Interlocking Operator replied “affirm”.

After the train passed signal D99-54, the Interlocking Operator contacted the Train Operator and informed the operator that this was a red signal overrun.

Vehicle data demonstrate the train was moving approximately 8 mph when it passed the red signal.

The switches at this location were clamped at the time of this event due to an ongoing track circuit malfunction that was preventing the interlocking operator from setting a lunar, or proceed, signal.

This malfunction was first reported around 5:30 a.m. the day of the event, approximately 18 hours before this red signal overrun. The malfunction was resolved early the next morning.

The Train Operator and Interlocking Operator received refresher training, including on radio protocols.

Rail Transportation produced and distributed a lessons learned document related to this event.

Metrorail has a long-open CAP related to radio discipline and protocols. While performance in this area has improved dramatically in recent years, Metrorail still must make significant progress, which must continue even after the minimum requirements for closure are met.

The WMSC continues to monitor Interlocking Operators through other oversight activities to assess whether there is proper training, focus and situational awareness.

Chair Hart requests WMSC staff review of lessons learned documents, coordination with rule book revision

Commissioners discussing radio repeat backs & radio communication processes

Invest. Pgm. Mgr. Quigley highlights WMSC's ongoing work with WMATA related to physical charactersistics training

W-0091 covers a red signal overrun in the Largo Town Center Tail Track, on approach to the Largo Town Center Station, on December 30, 2020.

The Operator of Train 421 moved their train more than 900 feet beyond a red signal to approach the station platform, without permission from the Interlocking Operator.

The signal was red due to another train waiting to depart the station on Track 2.

No one identified this red signal overrun for approximately 10 minutes.

The train passed the signal at approximately 16 mph at 2:41 p.m.

At 2:50 p.m., the Train Operator contacted the Interlocking Operator regarding the train’s location.
The Interlocking Operator then identified and reported the red signal overrun.

In an interview, the Train Operator stated that they thought the Interlocking Operator had provided a permissive block to the station platform, but that they had personal stress-related distractions that they were focused on at the time.

Implementing non-punitive self-reporting systems would have allowed this operator to report this stress issue rather than operate distracted.

WMATA policy requires a similar self-reporting system for fatigue. Metrorail has been planning for but has yet to implement such a non-punitive reporting program.

The investigation also identified a separate issue in the Largo Tail Track area.

Interlocking control via the Advanced Information Management (AIM) system has showed as “invalid” for an extended period, and there are issues with the Remote Terminal Unit and wayside equipment in this area.

This contributes to Train identification numbers not updating on the platform and creates the risk that duplicate Train IDs could be created when trains are re-blocked by Terminal Supervisors.

AIM does detect duplicate IDs when they show up in the system, but it is currently one of a long list of alarms. Metrorail is evaluating IT changes that could be implemented in coming months to mitigate this safety issue.

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.

Metrorail submitted its draft CAP proposals related to the Automatic Train Control and Signaling Audit on time at the end of last week. The WMSC team is now reviewing these proposals and other information related to the ATC system and will provide timely feedback to WMATA

The WMSC is also reviewing required revisions that WMATA submitted last week to corrective action plans to address radio communications deficiencies in rail yards and a lack of safety procedures for parts of rail yards that are not signalized.

Since the last public meeting, the WMSC has closed CAPs related to findings such as documented maintenance procedures and training, unauthorized use of personal electronic devices, and RWP training.

These closures are based on documentation, discussions, or inspections that demonstrated WMATA had completed all specified action items.

The WMSC has also approved for implementation 13 CAPs related to the elevated structures audit, and 15 CAPs related to the Rail maintenance machine (RMM) audit.

The WMSC continues to monitor closed CAPs through the regular inspection process to assess whether mitigations are working as intended.

Chair Hart asks for more specifc update related to elevated structures audit findings WMSC issued earlier this year
COO Samarasinghe: process being developed for load ratings & vehicle approval; interim load ratings being done for structures in worst condition

Audit update from program manager Davis Rajtik:

The Fitness for Duty Audit is nearing completion. The team is finalizing a draft report to transmit to WMATA in coming weeks for technical review.

The railcar audit team is also finalizing a draft report.

The Traction Power Audit team completed interviews this month and held the exit conference on June 18. The team is now reviewing follow-up documents that were identified based on the interviews, and the team expects to prepare the draft report this summer.

The next audit we are working on is the Fire Life Safety & Emergency Management audit. Interviews and field observations are planned for August. We expect this audit will be completed later this year.

One procurement resolution today

The Commissioners do have some further issues to address in Executive Session

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 August 3, 2021. We look forward to seeing you then.