Thread by @MetrorailSafety

Join us today (11/15) at 2:30 p.m. for our public meeting with updates on our daily oversight work including our oversight of Metrorail's 7000 Series Return to Service Plan, WMATA's Silver Line safety certification, safety event investigations & more wmsc.gov/meetings

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

Safety message of the day:

Winter is coming.
Clean your vents and chimneys, check CO alarms.
Don’t overload electrical circuits or leave candles lit overnight.
Close (the doors to bedrooms) before your doze

Chair Hart: Meeting includes updates on our ongoing safety oversight work, including Metrorail’s response to our order related to the 7000 Series, our oversight of WMATA’s Silver Line Phase 2 safety certification, and other actions to ensure Metrorail continuously improves safety

Chair Hart: We will also consider Metrorail’s proposed revision to its Public Transportation Agency Safety Plan – or PTASP. This is the high-level document that lays out Metrorail’s safety commitments, including the commitment to implement a safety management system.

Regarding the Silver Line, Metrorail set the opening date for today, and is now operating the first trains in passenger service on Silver Line Phase 2

Chair Hart: I am proud of the hard work the WMSC staff members have conducted for more than three years to oversee Metrorail’s safety certification process.

Chair Hart: This includes the WMSC staff’s continued data and document-driven approach to ensure that Metrorail carried out the necessary safety mitigations to address identified hazards.

Chair Hart: It is Metrorail following and continuously improving its processes and procedures that ensures WMATA operates the system as safely as reasonably practicable.

Chair Hart: The WMSC has played an important role in ensuring that Metrorail completed its safety certification process so that Silver Line Phase 2 could open today.

Chair Hart: We look forward to the positive impact this project will have for the region, and I congratulate the Metropolitan Washington Airports Authority and Metrorail on reaching this stage where they could begin passenger service.

Chair Hart: Reaching this milestone took years of hard work – and I congratulate all those individuals, organizations and leaders that have played a role in it.

Chair Hart thanks Greg Hull for distinguished service as WMSC Commissioner. Mr. Hull has resigned. The Commissioners will elect a new Vice Chair later in the meeting.

Chair Hart also notes Dr. Mayer had an unexpected medical issue, and shared his disappointment that he could not participate today, but he will be back to work in coming days.

Deputy CEO & COO Samarasinghe will provide the next updates.

COO Samarasinghe: Our team always works hard and around the clock – but that has been especially true over the last month.

COO Samarasinghe: Metrorail finally returned to a data-driven and iterative 7000 Series Return to Service Plan development process after Metrorail placed public and political pressure on itself in mid-October.

Last week, Metrorail completed its Silver Line Phase 2 safety certification activities necessary for the safe opening of the extension. Metrorail had previously set that opening date for today.

COO: I cannot thank our staff enough for the long hours and detailed, dedicated work they have put in on behalf of everyone across our region to carry out our important safety oversight work that increases the safety of Metrorail riders, workers and first responders.

COO Samarasinghe: Regarding Metrorail’s 7000 Series Return to Service Plan revisions, the WMSC continues to follow a data-driven approach, as specified in our December 29 order.

We also continue to emphasize to Metrorail WMATA’s own commitments in its Public Transportation Agency Safety Plan - and the safety management system laid out in that plan - to utilize data to mitigate known hazards and risks.

COO: Although it is disappointing Metrorail initially opted to again make misleading and false statements to the public & government officials rather than work constructively with us, I am glad WMATA eventually did return to an iterative plan development process based on the data

This allowed Metrorail to develop a Return to Service Plan revision submitted on October 25th that aligned with the available safety data. We provided our no technical objection that same day.

The mitigations in the revised plan reflect that Metrorail had essentially not run cars with low press tonnage axles that do not meet WMATA’s current specifications since May of this year…..

….that Metrorail has documented wheel migration on more than 80 7000 Series axles since 2017, that Metrorail had been running 7000 Series trains on specific lines since May of this year, and the ongoing investigation

We continue to oversee Metrorail’s implementation of its Return to Service Plan. Any adjustments are overseen as specified in our December 29 order

COO: Recent process failures where Metrorail has not adhered to its processes have included Metrorail on 9/22 placing a train into passenger service with 6 cars that did not meet its safety requirements, then keeping the train in service after the safety issue was identified

The train was put into passenger service at 6:10 a.m. and was not removed from passenger service until 7:35 a.m.

Metrorail had not generated a work order to inspect these railcars and Metrorail involved personnel in the process who were not trained on the necessary roles and responsibilities. Metrorail has distributed memoranda and adjusted IT systems as immediate mitigations.

In another example on November 3rd, an unintended release of railcars into passenger service demonstrated gaps in Metrorail’s general control of railcars that have not been cleared for passenger service.

Metrorail had designated the cars as being for training use only. However, the cars were still put into passenger service.

We also continue to monitor Metrorail’s implementation of other parts of its return to service plan – such as the multi-disciplinary Vehicle Track Working group chartered under the September 2nd plan revision

Metrorail has the opportunity to utilize this group to help break down organizational silos and to more effectively understand that rail transit relies on a system of systems – and the way those systems, such as railcars and track, interact with each other

In addition to our oversight of Metrorail’s Return to Service plan, our team continues to participate in the NTSB derailment investigation.

Regarding Silver Line Phase 2 – we observed Metrorail’s first Silver Line Phase 2 trains operating in passenger service just a few minutes ago.

We would like to congratulate the Airports Authority and Metrorail on the start of passenger service.

COO: Metrorail set this opening date after we had this meeting scheduled – and I am glad I could participate in both activities today.

We have been overseeing Metrorail and Metropolitan Washington Airports Authority safety certification of this project since our oversight program’s certification more than three years ago.

Metrorail has, of course, been working on this project much longer than that – including on its safety certification process, which is a critical element of Metrorail’s safety management system.

Consistently identifying hazards and mitigating the likelihood and severity of those hazards in a systematic way as documented in Metrorail’s policy and procedures is what provides for the overall safety of the Metrorail system.

To achieve this -- Metrorail must actually carry out all elements of its safety requirements – without bypassing any part of this holistic safety process.

Our work, conducted on an ongoing basis since 2019, to oversee Metrorail’s and MWAA’s Silver Line Phase 2 safety certification process has included field observations, document and data review, and regular meetings with Metrorail and MWAA

COO Samarasinghe: Our work identified hazards that Metrorail has now mitigated – making Silver Line Phase 2 safer for riders, workers and first responders.

COO Samarasinghe: Our work ensured that Metrorail developed mitigations for hazards that it had identified – making Silver Line Phase 2 safer for riders, workers, and first responders.

COO Samarasinghe: Our work ensured that Metrorail implemented mitigations to address hazards as required by its safety processes and procedures prior to opening the line – making Silver Line Phase 2 safer for riders, workers, and first responders.

Because we clearly and quickly communicated any issues that we found, Metrorail and MWAA were able to address those safety issues that we identified in a timely fashion.

Once Metrorail completed the safety mitigations WMATA had identified as required to mitigate known hazards to ensure the safety of riders, workers and first responders, the WMSC provided Metrorail with our concurrence last Thursday with Metrorail’s safety certification process

This occurred after our months and years of review – and less than 24 hours after Metrorail submitted final documentation that these safety mitigations are in place.

These mitigations include permanent, long-term fixes, as well as short-term temporary mitigations.

We will continue to oversee Metrorail’s activities now that they have incorporated Silver Line Phase 2 into the adopted regional system.

This work includes checking that Metrorail continues to implement these temporary mitigations it has committed to until permanent mitigations are in place in coming months.

Now that Metrorail has completed the mitigations and corrective actions needed to open the line and Metrorail set an opening date – opening the line to riders this afternoon – we look forward to the positive impact Silver Line Phase 2 will have for the region.

COO Samarasinghe: I again congratulate the Metropolitan Washington Airports Authority and Metrorail for reaching this point. And I thank the Airports Authority for its hospitality today.

We have, of course, also continued our other detailed safety oversight work throughout this busy period.

We identified late this summer that Metrorail had granted the highest level of Roadway Worker Protection qualification (Level 4) to individuals in the Safety Department’s Office of Emergency Preparedness who did not meet Metrorail’s written requirements for this qualification.

The training and experience of individuals granted an RWP Level 4 qualification is particularly important because it permits an individual to act as a Roadway Worker In Charge – the person responsible for the safety and protection of all other individuals in the work group.

After the WMSC identified that Metrorail was not following its safety processes, Metrorail told the WMSC in September that a waiver had been issued this past winter.

When the WMSC asked for a copy of that waiver, Metrorail could not provide any such waiver. Still, Metrorail had issued RWP level 4 qualifications to individuals who had not previously had experience as RWP-qualified personnel.

Due to the WMSC’s oversight and further data requests and review, Metrorail developed a draft permanent order that would provide specific mitigations required before specific personnel are permitted to obtain a Level 4 qualification without meeting Metrorail’s usual requirements

These mitigations include ensuring:
-At least six months of RWP Level 2 experience
-Observe at least 5 tunnel familiarization walks for jurisdictional first responders
-Perform as AMF and Watchman/Lookout duties with written assessment
-Verification by training department

This is just one other example of our safety oversight leading to safety improvements.

In this case, that means ensuring that only trained and qualified Metrorail personnel are providing for the safety of first responders such as firefighters and police officers participating in familiarization walks along active Metrorail tracks with train movement.

It is also an example of – due to the WMSC’s review of documents and data and persistence – Metrorail addressing a safety issue identified by the WMSC without the need for the WMSC to issue an order requiring it.

Metrorail’s safety management system – committed to by the WMATA Board and General Manager in WMATA’s PTASP – requires Metrorail to identify and address these issues

It should not take WMSC orders for Metrorail to follow its own procedures or to address known hazards. Of course, the WMSC will continue to take enforcement action if necessary.

We are investigating a series of Metrorail station overruns – including seven that occurred the weekend of November 4-6

These events pose risks such as the risk of collision.

The WMSC has raised this issue to Metrorail for several years, and Metrorail has placed its focus on creating definitions and procedures.

This includes Metrorail limiting station entry speeds to no more than 40 mph. Two of the seven overruns we are discussing now were over that speed

As an interim measure after these overruns, Metrorail further reduced speed commands entering specific stations.

Investigations into each of these specific events are ongoing – including review of data and necessary interviews with Metrorail personnel.

The investigations will consider contributing factors ranging from Vehicle-Track Interaction and mechanical and systems conditions, to human performance such as train operator attention, alertness, and training.

Metrorail is now gathering information on, and considering adding safety practices used at, other properties that may reduce the likelihood of these safety events.

In addition to the causes of the overruns, we are also concerned that during the investigation we identified that Metrorail was actively ignoring its documented procedures for required safety actions after a station overrun occurs.

These are procedures Metrorail developed to mitigate the risk of harm to riders and workers from subsequent unsafe actions or events following a station overrun.

After the WMSC identified this non-compliance with Metrorail standards, senior Metrorail individuals stated that the specific safety procedure – SOP 40 – was being deliberately ignored with their knowledge – in contravention of Metrorail’s safety commitments.

A Metrorail Permanent Order, adopted by Metrorail’s Rail Safety Standards Committee last month, states the updated procedure took effect November 1

The procedure requires that after a station overrun, the train continues to the next station at reduced speed, and, as Metrorail has done in the past, that the train and train operator be removed from service.

The train is removed and taken to a yard to determine whether any mechanical issue contributed to the safety event, and to prevent the continued operation of a train with such a safety problem.

The operator is removed to ensure that they are assessed, and undergo drug and alcohol testing to ensure these possible contributing factors are assessed.

This was the procedure approved in October by Metrorail’s Rail Safety Standards Committee that was effective November 1. The Rail Safety Standards Committee is coordinated by the safety department and includes representatives for the rail operations departments.

Senior Metrorail operations and safety individuals stated after these events where SOP 40 was not followed that the SOP was “paused” – however, Metrorail’s documentation, and months of work the WMSC had monitored on updates to the procedure, demonstrate that the SOP was in effect

Updates to the procedure that took effect November 1 were partly due to the corrective action that Metrorail developed to address safety issues identified in investigations including W-0163 relating to a station overrun and improper movement on the Green Line.

Metrorail adopted this revised SOP with additional safety protections after months of careful work.

Specifically, among the new additions to the procedure, Metrorail determined in the procedure that, after a station overrun, trains should not service the station, and should continue to the next station at restricted speed and then be offloaded.

Metrorail did not do that for any of these station overruns.

In response to the WMSC holding Metrorail to its own standards, individuals at Metrorail claimed that following the in-effect SOP as specified by the permanent order that had been approved by multiple Metrorail managers could introduce confusion.

Metrorail also claimed that the in-effect SOP could be ignored without following Metrorail’s documented safety processes required for changes.

The WMSC is deeply concerned about Metrorail senior leadership’s incorrect statements that a failure to follow procedures in place to control known hazards does not lead to unsafe conditions.

These statements are expressly contrary to logic and sound safety practices, as well as, more specifically, Metrorail’s PTASP and the WMSC Program Standard.

If controls in place to ensure the safety of passengers and workers are ignored, then those controls do not provide the intended level of safety for Metrorail passengers and employees.

Yesterday, after the WMSC had raised these safety issues, Metrorail provided a document dated November 10 that stated a different new station overrun procedure was in effect that had not been considered and acted on by its Rail Safety Standards committee.

This included an element that also appears to contradict Metrorail’s safety event investigation procedure, which requires equipment involved in safety events to be removed from service to ensure that a vehicle safety problem is not allowed to contribute to a second safety event.

Additionally, Metrorail informed the WMSC that it is further reviewing this week the SOP that the permanent order had put into effect November 1.

The WMSC is continuing to gather information from Metrorail regarding the actions in this case outside of Metrorail’s documented safety processes. We will determine whether any further WMSC actions are necessary.

As always, the WMSC endeavors to work with WMATA to ensure that Metrorail provides a system that is as safe as reasonably practicable for the public, employees, contractors, and first responders.

The WMSC is also examining Metrorail’s response to reports of smoke at Court House Station on November 7 and at Shaw-Howard U Station on November 10

We are gathering information regarding the exact timing of various events, conversations and actions to ensure that any conclusions we draw or actions we take are based on available safety information.

The WMSC has also taken note of Metrorail’s public statement regarding the November 7 event preemptively describing the decision to send trains into an area with reported smoke as “sound” even though the investigation has not reached this conclusion.

We are mindful of Metrorail’s history in this area – and Metrorail’s past promises to place safety over service.

Metrorail reported the November 7th event to the WMSC, but did not initially report this event to the FTA as required until the WMSC reminded Metrorail of the need to do so due to the evacuation for life safety reasons.

The WMSC continues to review and gather information to determine what if any actions may be required in addition to the investigation reports that will be presented at a future meeting.

As required by the infrastructure law enacted last year, the Federal Transit Administration issued special directives to each State Safety Oversight Agency on October 21st related to risk-based inspection programs.

We have already been preparing to build this program in accordance with the law, building on our existing activities.

We will demonstrate our inspection program meets the requirements before the October 2024 deadline.

In advance of this special directive, we had prepared adjustments within our organization to create the position of a Risk-Based Inspections Program Manager.

The FTA also issued two safety advisories last month. We have shared the information from those advisories with Metrorail, and have had further discussions with Metrorail about both the railcar passenger door inspection advisory and signal system safety and train control advisory

These are two areas the WMSC has already done detailed work on since 2019.

Metrorail has committed to responding to the signal system safety and train control advisory by April.

Metrorail stated it is developing a response regarding the railcar passenger door inspection advisory.

WMSC staff members participated in the FTA’s joint State Safety Oversight and Rail Transit Agency Workshop last month.

This is another opportunity for WMSC personnel to learn from experiences of other SSOAs, as well as to hear updates directly from the FTA.

Commissioner Lauby asks follow up questions regarding Metrorail not following its processes, and ongoing WMSC oversight and, if needed, enforcement action

Following additional questions from Chair Hart, we are moving on to the status update on orders related to Metrorail’s 7000 Series railcars from COO Samarasinghe

We continue to oversee Metrorail’s implementation of its Return to Service plan.

On 10/21, after Metrorail had placed public and political pressure on itself to create a revised return to service plan that was supported by available safety data, Metrorail returned to a more collaborative, iterative and data-driven approach to potential revisions to its plan

This allowed us, after ensuring that the plan was based on the available data, to provide on October 25th our no technical objections to Metrorail’s revised plan as submitted that day.

Metrorail’s plan – and the submission of any revisions – is required in accordance with the WMSC’s December 29th order.

We continue to carry out our work based on the available safety data and information.

This ensured that our team could act quickly and accurately to communicate with Metrorail and any other interested stakeholders, and to provide any necessary feedback and later our notice of no technical objections.

Mitigations in the revised plan reflect currently known data including that measurement exceedances related to wheel migration have been documented on more than 80 7000 Series axles since 2017.

Other known data include that the trains in use from June through September were selected from a specific pool of cars and Metrorail had operated them only on the Yellow, Green and then Red Lines

Metrorail’s data also demonstrated that other 7000 Series cars had generally not been operated more than a handful of miles since May.

The WMSC will continue to incorporate into these discussions and data reviews any information gleaned from our ongoing work related to the NTSB investigation into last year’s derailments

We continue to get new information, data, and analysis on an ongoing basis.

Metrorail’s 10/25 plan revision includes four-day inspection intervals, the introduction of some of those cars that Metrorail had effectively not used on mainline tracks for passenger service or non-passenger use since at least May, and controls on the introduction of those cars.

These controls include ensuring that these cars are carefully monitored and are only introduced to areas where Metrorail has had the opportunity to implement safety mitigations identified during the use of cars with axles that all meet Metrorail’s current specifications.

The plan includes a continued commitment from Metrorail to utilize its Vehicle and Track Working Group established under the September 2 plan to address known safety hazards and data.

The October 25th plan for the first time includes future phases that, if supported by available data, would further expand the use of the cars with at least one low tonnage axle to all lines, then, later, extend the inspection interval.

Metrorail is also continuing adjustments that have been made to referenced documents, training and inspection-related systems and processes due to the WMSC’s ongoing oversight.

This includes the instances on August 9, September 22, October 6 and October 7 where Metrorail did not follow its safety processes to ensure that only cars meeting Metrorail’s safety requirements were placed into service.

It also includes Metrorail developing necessary processes to review and act upon Vehicle Track Interaction data as specified in its plan, which we had identified Metrorail was not doing as it had committed to in the plan.

As it has been – this return to service plan process is and was unrelated to our longstanding process for oversight of Metrorail’s Silver Line Phase 2 safety certification activities.

Metrorail’s September plan included more than 330 railcars eligible for passenger service.

Under the September plan, Metrorail most commonly ran 11 to 14 7000 Series trains in passenger service each day, and never approached the 20 trains per day specified to ensure Metrorail’s safety processes were sound and a focus on carrying out those safety processes as designed.

Since the October 25 plan revision, which maintains the same four-day inspection interval, Metrorail has chosen to operate just over 20 7000 Series trains in passenger service on several days.

Chair Hart and Commissioner Lauby ask about controls in place to detect wheel migration, opportunities Metrorail has to further limit the risk of wheel migration occurring, as investigation continues. These activities are specified in Metrorail's plan and associated procedures

Commissioner Bobb asks about WMSC's ongoing workload assessment process that helps determine staffing levels

Next up: Audits update

The WMSC transmitted the first two draft audit reports to Metrorail this month of our next triennial audit cycle.

We transmitted the draft Track Audit to Metrorail on November 1st for Metrorail’s technical review.

Earlier today, we transmitted our draft Audit of Metrorail’s Internal Safety Review Program and associated corrective actions for Metrorail’s technical review.

As with each of our audits, the work on these audits included extensive reviews of Metrorail documents, onsite work such as interviews, and, in the case of the Track Audit, site visits to various parts of the Metrorail system.

Our audits assess Metrorail against the relevant criteria such as the requirements of Metrorail’s Public Transportation Agency Safety Plan, requirements specified in other Metrorail documents such as SOPs and orders, and regulatory requirements.

These audits cover all aspects of Metrorail’s Public Transportation Agency Safety Plan over a three-year period, and are designed to proactively identify safety issues.

We are now working on our Structures Audit. The team has been reviewing documents and data provided by Metrorail, and is preparing for site visits and interviews in coming weeks.

Our next audit after that will be of Metrorail’s Roadway Maintenance Machine program. The site visits and interviews for this audit will be done this winter.

Corrective Action Plan (CAP) updates, also from Ashley Rhodes:

Since your last public meeting, we have closed 5 CAPs and have approved 4 Metrorail CAP proposals for implementation

We have now approved all 13 of Metrorail’s Station Maintenance, Elevator and Escalator Audit CAPs for implementation.

We just completed our review yesterday of Metrorail’s first batch of CAP proposals to address the findings and recommendations from the Communications Audit issued in September.

The WMSC approved two CAP proposals for implementation, and provided feedback to Metrorail on seven other proposed CAPs that need adjustments to address the findings in a timely fashion.

Metrorail requested, and the WMSC granted, an extension for two other CAP proposals related to the Communications Audit. As those proposals were submitted later, our team is still reviewing those later submissions.

Regarding the order we issued August 4 on Automatic Train Control room inspection, maintenance and cleaning, the WMSC received Metro’s latest revised CAP proposal last week. It is under review by our team.

Overall, Metrorail currently has 132 open WMSC CAPs, in addition to CAPs that remain under development.

The five CAPs recently closed include two CAPs addressing safety issues identified by our Railcar Audit issued last year.

CAP C-0135 included a process to ensure safety certification procedures are followed – including that only certifiable items lists approved by the Safety Certification Review Committee are used.

Metrorail provided documentation this was being followed. This is in association with Metrorail’s failure to follow this safety process regarding 6000-Series railcar overhaul work, specifically including the 6000 Series couplers. This related to train pull-aparts in fall 2020.

C-0141 related to the implementation of a process for job plans and engineering case studies to ensure uniformity and to prevent conflicting direction. Work included development of standardized formats and identification, and the review of existing plans.

The fifth closed CAP was superseded by a similar CAP Metrorail has developed to address a finding from this spring’s Rail Operations Audit

Silver Line Phase 2 Status report from Safety Certification Program Manager Tino Sahoo

Due to our extensive work, frequent communication with people at multiple levels of WMATA, and our communication of items we identified as we found them, we could quickly work through an intensive but detailed review and spot check of thousands of pages of WMATA documentation

This includes issuing our concurrence less than 24 hours after we received final necessary documentation from Metrorail.

Sahoo: I appreciate the support of the WMSC team, including our subject-matter experts, throughout this process to ensure that Metrorail addressed gaps in safety documentation and mitigations.

We will continue to monitor Metrorail’s and the Airports Authority’s work on permanent mitigations that, in coming months, are planned to replace temporary mitigations in place today.

This work includes monitoring of Metrorail’s interim mitigations – to ensure these are carried out.

Examples of interim mitigations include equipment or areas that will not be used until safety issues are addressed, the stationing of personnel to assist with emergency evacuation if needed, and a fire watch when certain activities are carried out in specific locations.

Sahoo also providing update on Potomac Yard Station

Due to construction status, Metrorail planned to open the new tracks and utilize specific systems earlier this month for trains to pass through without stopping until the station is complete and necessary safety certification steps for those facilities have been carried out.

To provide for this activation of the new tracks and specific systems in passenger service, Metrorail developed a Temporary Use Notice.

The WMSC carefully reviewed this document in conjunction with other safety certification documentation and information, and communicated specific questions and apparent gaps in safety documentation or mitigations to Metrorail.

Metrorail and the WMSC worked collaboratively to ensure a timely resolution. This included ensuring that Metrorail had the necessary testing, documentation and safety mitigations in place to address these safety items

This led to the WMSC concurring on November 4th that the revised Temporary Use Notice was developed in accordance with, and included necessary mitigations to address, items specified by Metrorail’s safety certification process.

The WMSC will follow Metrorail’s continued safety certification of the Potomac Yard project. Metrorail is required to receive the WMSC’s concurrence with its safety certification process before opening the station to passengers.

First group of safety event investigation reports being presented today by Investigations Analyst Natalie Quiroz

The first two reports today relate to improper roadway worker protection in the area of the King Street Station in Alexandria.

In both of these events, the relevant trains were heading outbound – toward where the Blue and Yellow Lines diverge just south of the station.

Investigation W-0184 covers an event that occurred on June 15th.

In this event, the Advance Mobile Flagger (AMF) on the platform stopped briefing train operators that there were workers on the tracks ahead and that the train operators had to proceed at reduced speed.

The AMF did not brief three trains. Two trains were Yellow Line trains taking a different route. One of these trains was a Blue Line train that was traveling in the direction of the personnel on the Blue Line tracks.

Metrorail rules require the AMF to brief all trains.

Without a briefing directing them to travel at reduced speed, the Train Operator of that Blue Line Train, Train 402, proceeded toward the work crew at more than 50 miles per hour.

This was a near miss.

Upon seeing the work crew – the Train Operator sounded the horn, applied the brakes, and reported the event to the Rail Operations Control Center

The crew was safely picked up by another train.

The AMF stated that they thought they had heard the Roadway Worker In-Charge tell them on the radio to “stand down” so they stopped performing their duties.

This is not an instruction that would be provided in these circumstances under Metrorail rules and procedures.

This is not an instruction that would be provided in these circumstances under Metrorail rules and procedures.

The probable cause of this event was insufficient training and supervisory oversight of AMF activities. Contributing to this event were radio communications systems deficiencies.

Despite these identified deficiencies, Metrorail’s Office of Radio Communications stated there were no abnormalities. The WMSC’s Communications Audit (9/29/22) included findings requiring corrective action plans to ensure that problems are properly identified and addressed.

The second event, on June 24th, involved apparently conflicting instructions from an AMF and the Rail Operations Control Center.

A Yellow Line Train Operator who was properly held at the platform by the AMF due to the work crew having Foul Time protection on the Blue Line departed the station when the Rail Traffic Controller stated that they were providing a clear signal and switch alignment.

The investigation identified that, contrary to Metrorail’s roadway worker protection rules, Metrorail has been allowing trains to proceed if the route is expected to take the train away from the protected location.

The AMF, who was following the written procedure, immediately reported to the ROCC that the train operator had left the station without being briefed.

The probable cause of this event was Metrorail’s practical drift away from written roadway worker protection safety procedures.

Metrorail is modifying the AMF rule as an interim measure while Metrorail’s broader review of its RWP programs proceeds.

Metrorail also conducted safety briefings and distributed a safety bulletin on the importance of holding vehicle movement when personnel have foul time protection.

Commissioner Lauby asks about Metrorail's AMF program

In these two events - one AMF did the correct thing, other did not - they are looking at changes to the program and have increased compliance checks

COO Samarasinghe provides brief recent history of Metrorail's RWP program, and Metrorail's ongoing evaluation of overall program to meet safety needs of WMATA

The next investigation relates to improper train movement – beyond the limits of a permissive block – on June 23rd.

In this event, W-0186, riders had been offloaded from a train due to a mechanical issue.

Metrorail then cut out the trucks on one car with heavy brake odor. This allows the train to move without those friction brakes being applied.

Due to the reduced braking functions, and therefore the increased risk of collision, Metrorail rules require the train to then move only with employees on board and only under a permissive block
A permissive block is a segment of track with no other vehicles on the roadway ahead

The Rail Controller had provided this block to the Train Operator to the end of the Metro Center platform. However, the Train Operator continued beyond that block and did not request another block until after the front of the train was about 300 feet past McPherson Square

The Rail Controller then provided a permissive block to Farragut West Station where the Train Operator was removed from service.

The probable cause of this event was a lack of supervisory oversight to ensure that safety rules are consistently followed, including regarding permissive blocks and 100% radio repeat back of instructions. Contributing to this event were radio communications systems deficiencies.

The Train Operator and Rail Controller reported radio communications challenges during this event. Still, Metrorail’s Office of Radio Communications stated there were no abnormalities. Metrorail is developing CAPs to address related findings of the WMSC’s Communications Audit.

Metrorail committed to increased observations of radio repeat back procedures. Metrorail issued a safety bulletin regarding ROCC post-event testing requirements, and emphasized the importance to ROCC controllers of receiving word for word radio repeat backs.

Commissioner Lauby: One reason the 100% repeat back requirement is there is to mitigate radio communications quality issues

Investigation Program Manager Adam Quigley presenting the next reports

Investigation W-0187 relates to a serious injury at Cheverly Station during this summer’s long-term Orange Line shutdown.

This summer’s work included structural repairs and rebuilding platform edges at Orange Line stations east of Stadium-Armory Station.

In this case, a construction foreman stepped onto an unsecured platform edge and fell onto the roadway. The granite edge then fell on the construction contractor. The individual broke their leg.

The investigation demonstrates that Metrorail had not ensured that hazards identified in the job hazard analysis were properly mitigated, or that sufficient safety plans were in place.

Following this event, Metrorail placed safety barriers and rope along the platform edge while granite edge pieces were being removed at the stations undergoing platform repairs.

Metrorail committed to more comprehensive work on hazard documentation and avoidance, better future safety guidelines, and to ensure that the Safety and Capital Delivery Departments perform audits of contractor safety plans.

In addition, the contractor held a safety standdown, and stopped work until adjustments were made

Metrorail did not report this accident-level event involving a broken leg to the WMSC and FTA within two hours as required.

Metrorail reported this event nearly nine hours after the event, at 7:59 a.m. the following day.

The WMSC investigations team continues to provide guidance to Metrorail on the importance of complying with the WMSC Program Standard and federal regulation.

Final investigation report of the day relates to Metrorail’s response to a fatality on the Red Line between Brookland and Rhode Island Avenue Stations on May 15th.

A member of the public who had entered the tracks without permission was struck and killed by a train in the short tunnel section in this area.

The Train Operator was not aware that they had struck a person, but reported to the Rail Operations Control Center just after 2 p.m. that an intercar barrier had come unattached on the front of their train as they approached Rhode Island Avenue

This is the chain that connects between cars in the middle of a train as a safety measure to ensure people boarding the train only step through open doors and not through the gap between railcars.

At the station, the Train Operator informed the Rail Controller that the train may have struck something, since the barrier was in two pieces.

The Rail Controller allowed the train operator to continue in service, and dispatched a railcar mechanic to meet the train at Gallery Place Station.

Approximately 10 minutes after the Train Operator first reported the detached intercar barrier, the Station Manager at Rhode Island Avenue reported an emergency on the roadway

A member of the public had walked to the platform from the roadway and approached a Metrorail employee on the platform. This person told the employee that a person they were with on the roadway had been struck by a train.

A Rail Operations Information Center employee in the ROCC called for a D.C. Fire and EMS response.

D.C. Fire and EMS arrived at Rhode Island Avenue at approximately 2:28 p.m. The Metro Transit Police Department separately stated they established command at Brookland Station at approximately 2:34 p.m.

Trains 105 and 111 were offloaded for their operators to conduct track inspections. These initial inspections did not identify anything.

Metrorail later conducted another track inspection of the same area with a train operator and other personnel in the operating cab.

At 2:46 p.m., approximately 45 minutes after the event occurred, an RTRA Supervisor on this subsequent train with MTPD reported the person struck had been found on the roadway.

Following this event, Metrorail conducted an after action review and distributed areas of improvement to ROCC personnel regarding SOP 1A, emergency response.

Rail Controllers also underwent refresher training on SOP 11 governing train collision procedures

Metrorail committed to reviewing and updating procedures to ensure that track inspections from rail vehicles used to investigate unusual conditions are performed in a consistent manner.

Metrorail is also continuing work to implement corrective action plans related to the WMSC’s Audit of Emergency Management and Fire and Life Safety Programs issued earlier this year.

The investigation reports adopted today are available at wmsc.gov/oversight/repo…

Commissioners now ready for resolutions and other actions

First, Chair Hart notes that the commissioners approved the draft FY24 budget and work plan via written vote, and this draft has been transmitted to D.C., Maryland and Virginia on time in accordance with the jurisdictional funding agreement

Next – Commissioners will consider Metrorail’s Public Transportation Agency Safety Plan (PTASP)

This plan lays out Metrorail’s commitment to a strong safety culture that reaches everyone from frontline workers and supervisors to executive management. Metrorail is required to review and update this plan at least annually.

The WMSC oversees Metrorail’s implementation of this plan

COO Samarasinghe: This is Metrorail’s second annual revision to its Agency Safety Plan. The initial version was effective almost two years ago, in December 2020.

This change, and the annual revisions of the PTASP, must meet WMSC requirements and federal regulations.

The PTASP is required to include a safety management system – or SMS – approach.

The objectives here are safety, accountability, increased use of data, and a clear commitment that every employee from the frontline worker, to the supervisor, to managers and to executive leaders are accountable for upholding the commitments to safety.

It takes training, avenues for reporting safety issues, and communication to keep everyone up to date on how these reports are being used to proactively improve safety.

The goal is to be proactive – by identifying and addressing issues before an accident occurs, and by ensuring continuous learning and open dialogue.

The WMSC has reviewed and provided feedback on multiple drafts of WMATA’s Agency Safety Plan revision, leading up to this final version

WMSC staff reviewed Metrorail’s final draft for compliance with our Program Standard and federal regulation, and, in accordance with our Program Standard, we transmitted conditional approval to Metrorail prior to the WMATA Board approving this PTASP on September 22.

Some of Metrorail’s revisions this year include items required by last year’s infrastructure law such as:
•The creation of a Labor-Management safety committee
•Expanded employee safety training
•Items related to transit worker assaults

In addition – the plan includes updates to planned SMS implementation timelines and tasks to progress these items over the coming year.

Generally - The PTASP specifies Metrorail’s safety commitments, including specific standards Metrorail must meet. Metrorail’s other documented policies and procedures are implemented under the umbrella of the PTASP, this high-level document.

As the State Safety Oversight Agency for Metrorail, the WMSC must approve Metrorail’s PTASP revision before it can be implemented.

COO: The WMSC oversees Metrorail’s implementation of its PTASP. This is a basic element of our Program Standard, and a basic responsibility specified in the WMSC Compact – that when Metrorail makes safety commitments, we expect Metrorail to follow those commitments.

If the WMSC identifies that Metrorail is not following its safety requirements – then we take the necessary action to require Metrorail to correct that safety issue.

The WMSC will continue to oversee this implementation and will continue to identify areas where Metrorail can and must get better.

Commissioners approve resolution on WMATA's PTASP revision

Final action item of the day – Commissioners select Mike Rush as their new Vice Chair

Chair Hart: We expect to hold our next public meeting on December 13, 2022.