Thread by @MetrorailSafety

Join us for our public meeting today (12/13) at 12:30 p.m. Watch live on YouTube/Zoom. wmsc.gov/meetings

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

Safety message of the day: Safety messages.

Starting with a safety message can help prevent an accident, injury or death.

You do not need to limit this safety step to work-related events.

Be careful cooking, talk about allergies, make sure people don’t drink and drive.

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

Chair Hart: For Metrorail to achieve this goal, it must ensure that its leadership maintains existing progress, and makes clear that following Metrorail’s safety procedures is critical to the safety of passengers and personnel.

CEO Mayer: We continue our hard work overseeing Metrorail’s 7000 Series Return to Service Plan, and participating in the derailment investigation. This includes data review and analysis.

CEO Mayer: We continue to raise and discuss specific items related to Return to Service Plan data, and whether Metrorail is fully considering and acting upon this data.

CEO Mayer: For example, our analysis of Metrorail’s Vehicle-Track Interaction data demonstrates differences among railcars and among parts of the system that present opportunities for Metrorail to act on trends to make further safety improvements.

CEO Mayer: Metrorail’s plan requires it to conduct this and other analysis and action in a collaborative fashion through the Vehicle-Track Working Group created under the September 2nd plan. This group has not yet taken significant action.

CEO Mayer: We continue to follow a data-driven approach as specified in our 12/29 order. We also continue to emphasize to Metrorail WMATA’s own commitments in its PTASP, and the safety management system laid out in that plan, to utilize data to mitigate known hazards and risks.

Metrorail submitted procedural revisions to its plan that include more streamlined data entry & additional personnel to perform measurements. The WMSC provided timely feedback and provided Metrorail with an opportunity early last week to clarify items.

CEO Mayer: The derailment investigation is continuing to progress. As previously discussed, available data continues to indicate differences in different parts of the system and track infrastructure and variations among 7000 Series railcars.

As always, this is just one element of our work.

CEO Mayer: For example, we continue to provide detailed comments and concerns related to Metrorail’s latest automatic train operation activities.

This includes questions about timelines, training, roadway worker protection, and the preparedness of not just the physical systems but also the organization to effectively and safely operate what is a completely new system for most current Metrorail frontline employees.

Also related to safety certification, we continue to oversee Metrorail’s activities regarding Silver Line Phase 2, including Metrorail’s compliance with the safety mitigations put in place to open the line.

CEO Mayer: Regarding an item discussed at our last public meeting – Metrorail has now implemented its Station overrun standard operating procedure.

CEO Mayer: As discussed in our last public meeting, senior Metrorail leaders had, at that time, directed personnel to ignore the in-effect procedure.
Due to the WMSC’s oversight, Metrorail is now following its safety procedure.

We will continue to monitor this implementation through our investigations team.

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

It is also an example of Metrorail addressing a safety issue identified by the WMSC without the need for the WMSC to issue an order requiring it.

CEO Mayer with several updates on ongoing investigations:

1.investigation of a Nov. 16 event where a Train Operator passed roadway personnel at excessive speed has identified that the Train Operator had worked 30 days straight.

The WMSC has gathered information on Metrorail’s train operator availability that demonstrates Metrorail has and has had far fewer train operators available than its schedule requires for operations.

2.We are investigating several safety issues related to an evacuation of Gallery Place Station on Nov. 23.

CEO Mayer: Preliminary investigation indicates that Metro Transit Police Department and Metrorail Office of Emergency Preparedness personnel entered the roadway to examine an unattended bag without required Roadway Worker Protection in place.

MTPD and OEP personnel did not permit a Rail Supervisor to remain with them on the lower level platform, which contributed to a lack of communication with Rail Controllers responsible for that section of the roadway.

MTPD officers used the ETS box to de-energize power without communicating with the Rail Controllers or the Power Operations Center. Metrorail requires any Metrorail employee utilizing an ETS box to contact ROCC and not leave the box until successful communication

CEO Mayer: In addition, this investigation demonstrates that Metrorail is still not recording all Rail Operations Control Center communications.

Telephone communications with Rail 1, who leads the room on a given shift, are not being recorded when the ROCC is operating from the Jackson Graham Building, Metro’s former headquarters.

This was found not only for this event: Follow up checks by the WMSC show this line has not been recorded for a prolonged period.

We are also aware that other communications recordings that are made in the JGB ROCC are not properly labelled, and that other phone calls are shown as occurring, but without the actual recording being available.

Combined, these recording deficiencies have confused and delayed safety investigations.

The WMSC identified recording deficiencies in our ROCC Audit issued in 2020, and in our Power restoration order issued earlier this year. Metrorail has open requirements and corrective action plans related to this, including C-0051.

Although the WMSC has confirmed that Power Operations Center lines are being recorded, we continue to be concerned that without complete recordings, Metrorail is unable to fully investigate and learn from safety events.

3.We are also investigating a Red Signal overrun that occurred on December 6 on the Blue, Orange and Silver Line tracks.

Based on communications during and after the event, and the investigative interview, the Train Operator did not know where they were in the system.

This created the risk of a collision with workers, as the signal was red to protect a work crew.

Metrorail had just certified this train operator for the first time the week before this event.

This is another example of the need for improvements to training including the implementation of physical characteristics training as required under a Corrective Action Plan Metrorail is implementing to address a finding from our Rail Operations Audit issued this spring.

4.We are continuing to investigate recurring Metrorail remote-control issues affecting signals, the power system, and emergency ventilation fans, including repeated losses of communication with Remote Terminal Units.

This includes an investigation of a November 16 complete loss of remote control and monitoring of significant parts of the system.

This means that the ROCC could not monitor the locations of trains, could not control third rail power, and could not activate emergency ventilation fans in the case of an emergency.

Similar issues have apparently happened prior to WMSC oversight. Widespread remote control issues also occurred this summer, including particularly lengthy outages at several Red, Orange, Blue and Silver Line stations.

CEO Mayer: We expect to bring a final investigation report for consideration on this Nov 16 event in coming months. We will also continue to examine other related events and systems and any associated Metrorail procedures as part of our other oversight work.

COO Samarasinghe with a status update on orders related to 7000 Series railcars

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

Metrorail has submitted changes to its October 25th plan that will adjust how exactly measurements are recorded and that will expand the personnel used for this task.

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

COO Samarasinghe: The plan continues to be the data-supported plan that aligns with the letter we sent Metrorail on October 17 providing Metrorail with examples of plans that were supported by the available safety data.

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

So far, Metrorail has progressed to the second phase of this plan.

Over the last month, Metrorail has generally operated between 20 and 30 7000 Series trains each day in passenger service.

COO Samarasinghe: We remain concerned about whether Metrorail is fully analyzing and acting upon available safety data as specified in the plan to make continuous safety improvements.

This includes our analysis of Metrorail’s Vehicle-Track Interaction data demonstrating specific railcars and locations with a high number of hits that indicate unusual interaction between the vehicle and track systems.

COO Samarasinghe: We have provided questions to Metrorail about these examples of safety data indications on specific railcars and track locations.

COO: Metrorail established a Vehicle and Track Working Group at the WMSC’s suggestion under its September 2 Return to Service Plan, but has not taken advantage of this interdisciplinary group to address known safety information.

The WMSC also continues to review data and analysis from the derailment investigation and will continue to assess this information to determine whether additional or adjusted actions are warranted to safely operate 7000 Series or other railcars.

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

Audit updates: Metrorail provided technical comments on our draft Track Audit. WMSC team is carefully reviewing the information and additional follow-up documents we requested for clarification. We expect to issue this report in coming days.

Our second audit report of our new triennial cycle covers Metrorail’s Internal Safety Review program and associated corrective actions. We expect to receive any comments from Metrorail by the end of this week. We will then consider those and issue a final report in coming weeks.

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, specific 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.

We are completing on-site work and interviews for our Structures Audit this week. Our team will then review follow-up documents.

In the new year, we will conduct on-site work and interviews for our audit of Metrorail’s Roadway Maintenance Machine Program.

Corrective Action Plan updates: 5 CAPs closed since last public meeting.

Several CAP proposals remain in the development and review process

CAPs closed recently include C-0057 addressing a 2020 finding related to high turnover in the ROCC. The CAP included improved onboarding practices, clear communication of expectations, and a new exit interview process.

Metrorail has also implemented safety sensitive medical exams at the time of hire as required by Metrorail policy, leading to the closure of CAP C-0122

Three other closed CAPs relate to findings from the ATC Audit

Safety Certification Oversight update

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 carry out all elements of its safety requirements without bypassing any part of this holistic safety process.

This work includes Metrorail’s safety certification process.

We are continuing to monitor Metrorail’s implementation of interim safety restrictions and other mitigations designated as part of Metrorail’s Silver Line Phase 2 safety certification.

Other projects that require our concurrence prior to Metrorail activating them in passenger service include the new Potomac Yard Station and Metrorail’s possible initiation of automatic train operation or automatic door operation.

Regarding Metrorail’s work on Automatic Train Operation and Automatic Door Operation, the WMSC has identified issues and communicated detailed questions for several years.

This includes information prior to and within the ATC Audit issued May 2021, additional gaps in Metrorail’s efforts including related to test plans and orders in late 2021 and early 2022, and specific safety questions the WMSC has continued to raise over the last several months.

Metrorail’s operations have also changed both since the system opened and since Metrorail shut down Automatic Train Operation in 2009. That includes changes related to conducting work and Roadway Worker Protection.

The WMSC’s automatic train control and signaling team and safety certification oversight team continue our careful oversight and consistent communication with Metrorail.

This includes issues related to WMATA’s possible schedule and sequencing of testing, training, technology upgrades/adjustments, rule and procedure reviews and the other intensive work needed if WMATA chooses to continue pursuing activation of ATO in all or parts of the system.

This is a significant effort that requires Metrorail ensure its entire organization is ready for such a change to activate these features for the first time in the current environment.

Metrorail’s documentation provided to the WMSC states WMATA believes the benefit of implementing ATO for the first time since 2009 may be a possible reduction in rail car maintenance requirements. WMATA believes ATO would also make rides more comfortable when stopping at stations

Metrorail’s current plan would require additional new software changes that have not yet been developed and procedural steps by those in the Rail Operations Control Center.

Metrorail’s documentation states that WMATA believes the safety benefit of implementing automatic door operation would be a reduction in instances of doors opening on the wrong side of the train. So far this year, there have been 8 instances of wrong side door openings.

The automatic door operation setting Metrorail is considering is designed to have the train doors automatically open when the train is properly berthed at the platform, but then have the Train Operator manually close the doors.

We are awaiting further information and responses from Metrorail to our latest questions and concerns that we communicated on November 18

Potomac Yard is an infill station Metrorail is building on the Blue and Yellow Lines in Alexandria, along with associated new track and systems.

The tracks and some systems opened last month after Metrorail completed the necessary safety certification work on those systems and the WMSC concurred with Metrorail’s temporary use notice.

The WMSC’s concurrence with the temporary use notice was required because this is a project undergoing WMSC in-depth review. We will follow Metrorail’s continued safety certification of the Potomac Yard project, and continue to raise any issues as they are identified.

We have continued to maintain awareness of Metrorail work on potential Automated Wayside Inspection Systems. These are the updated systems Metrorail began installing earlier this year before pausing most work on these systems.

As we communicated earlier this year, we are reviewing the first location for our concurrence, and Metrorail will follow that same validation and examination process for the other seven sites.

Moving on to final safety event investigation reports – Investigation Program Manager Adam Quigley presenting first

The first report today, W-0189, relates to an evacuation for life safety reasons at Ballston Station on August 11

On August 11, 2022, toxic gas from overheated Metrorail batteries filled part of the Ballston Station.
These batteries support the uninterruptible power supply – or UPS – for the station’s Train Control Room.

The Arlington County Fire Department determined that a fire alarm was due to gas coming from the battery room at the southeast end of the station

The Metrorail personnel involved in the response did not know about the battery safety switch outside the room that can be used to cut power.

After forcing entry into the room, Arlington County Fire upgraded the response to a hazmat response. This was 47 minutes after the initial alarm.

At that point, responders communicated that trains should bypass the station and riders should be evacuated for their safety.

During the time the station was evacuated and closed to riders for their safety, one train stopped at and serviced the station, placing riders in hazardous conditions.

In addition, Metrorail did not follow its emergency response processes. This includes the incident command process. Information was also not consistently and clearly shared.

Rail Controllers made general announcements on the Ops 4 channel for some trains to turn off environmental systems when bypassing Ballston Station. No similar announcements regarding the environmental systems or bypassing Ballston Station were made on the Ops 2 channel

Train Operator who serviced Ballston Station during the evacuation was in the Ops 2 radio territory when the announcements were made on Ops 4

The Ops 2 Rail Controller made an announcement on their channel only after the Train Operator serviced the station during the evacuation

The investigation shows that Metrorail had kept the UPS in service beyond the end of its useful life, allowing it to run to failure.

The battery charger was not working properly. This led to excess energy being fed into the batteries.
In addition – the ventilation unit in the room was not operating correctly, and the separate exhaust fan was also not working.

The batteries overheated. System data indicates the toxic gas release began approximately 15 hours after the improper charging began. The acid in each battery began to boil.

The WMSC had raised similar ancillary room maintenance concerns to Metrorail in the spring, and further documented these issues in our August 4, 2022 Train Control Room order, the week prior to this event.

Metrorail had committed in the spring to special inspections of ancillary rooms for these types of ventilation system deficiencies, but had not continued those inspections until after the WMSC’s order.

Metrorail opened the battery disconnect to separate the batteries from the UPS at about 12:30 a.m. The battery bank later cooled down and stopped emitting the toxic gas.

The power cutoff was delayed due to unclear labelling of cutoffs and insufficient training and communication of actions to take in emergencies related to battery-supplied systems.

Metrorail developed a number of corrective actions to address issues identified during this investigation. In addition Metrorail is implementing CAPs tied to the Emergency Management and Fire and Life Safety Programs Audit, August 4 order, and other related findings.

Investigation, W-0190, relates to a derailment at New Carrollton Station on August 29

A flat car derailed during the long-term shutdown of this part of the Orange Line

Investigation W-0191 relates to a serious injury at Largo Town Center Station (now named Downtown Largo Station) on July 28

Three further investigation reports, each related to evacuations for life safety reasons

W-0192 relates to evacuations of Building B at Greenbelt Rail Yard on July 11 and 12 for reported gas leaks

W-0193 relates to an evacuation of Cleveland Park Station on July 29, 2022 due to a fire by the station’s platform escalator.

Final report is W-0194, a July 18, 2022 evacuation of Mount Vernon Sq Station. This was due to a bomb threat reported by MTPD. Nothing was found.

One resolution on the agenda today – consideration of the annual independent financial audit and associated report for WMSC fiscal year 2022

Chair Hart: I would like to thank Secretary-Treasurer Farrar-Dyke for her role, and our staff for their hard work both on an everyday basis to ensure that we are meeting all requirements, and as part of the audit process to provide the necessary information and documentation.

Chair Hart: We are proud of our staff for carrying out their work in such a professional and efficient manner.

Sec-Treas. Farrar-Dyke: We’re very proud of our staff and our commissioners for this audit that includes an unmodified, or “clean”, opinion on the WMSC’s financial statements through the end of our fiscal year last June

The auditors concluded that the financial statements present fairly, in all material respects, the financial position of the WMSC.

This annual audit is required by the WMSC compact, and, upon adoption, will be transmitted as required.

Chair Hart: As a reminder, you can always report any concerns through our website (wmsc.gov/report/), through our social media channels or by email.

We expect to hold our next public meeting on January 24, 2023.