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Metro's mixing of signal part brands could have caused crash, maker tells NTSB

By Lena H. Sun, Ann Scott Tyson and Joe Stephens
Washington Post Staff Writers
Thursday, February 25, 2010; A01

Metro's decision to mix different brands of signaling equipment -- despite a warning from one of the manufacturers -- could have caused the June crash that killed nine people, a senior engineer with the company said Wednesday at a federal safety hearing.

Five days before the accident, Metro crews replaced a key piece of equipment with one from another manufacturer. After the equipment was replaced, the circuitry malfunctioned, and no one at Metro detected the problem, investigators have said.

The National Transportation Safety Board, which is conducting a three-day hearing into the accident, plans to issue a formal finding on the cause by mid-June. Information released by the board has pointed to possibly faulty and aging equipment in the failure of the automated crash-avoidance system. But the information on the signaling system attempts to shift blame to Metro's maintenance, testing and installation procedures. Alstom, the equipment manufacturer, like Metro, potentially faces millions of dollars in liability judgments from victims' lawsuits.

"Alstom believes that the use of third-party components . . . presents, not only a customer quality issue, but also constitutes a serious and increasing risk to overall signaling system safety," wrote Alstom, which makes much of Metro's train detection equipment, in a Sept. 7, 2004, letter. Neal Illenberg, Alstom's site safety officer, said the letter was distributed to "hundreds of" customers, including Metro.

In the letter, Alstom said the use of non-Alstom components, without "rigorous industry design and safety standards," had resulted in a series of failures in track switch machines, a different kind of system, and had resulted in operational problems, including a freight-car derailment. Alstom warned against mixing components across all train control systems.

The information was disclosed as Illenberg questioned Metro witnesses Wednesday. Parties to the investigation, such as equipment manufacturers, are allowed to examine witnesses. The hearing, which is scheduled to end Thursday, is exploring what happened and examining broader issues of safety and oversight.

A copy of the letter and the 24-page distribution list obtained by The Washington Post shows that 19 Metro officials were on the list, including Harry Heilmann, then a supervisory engineer. Heilmann retired Feb. 1 as an assistant chief engineer for Metro but is testifying on Metro's behalf.

Asked about the letter, Heilmann said, "I'm not familiar with that correspondence."

In addition, Illenberg said an Alstom employee gave an oral warning to another Metro engineer about the risks of mixing equipment from different manufacturers during discussions about an engineering bulletin issued on the topic in October 2006. The bulletin gives instructions about installing equipment made by Union Switch & Signal in track circuits made by GRS, the company that Alstom took over. Union Switch & Signal is now Ansaldo STS USA. Alstom and Ansaldo are the two major companies that make this type of equipment.

The Metro engineer, Johann Glansdorp, "was told Alstom would not consent with the mixing of equipment," said Illenberg, the lead Alstom representative for the investigation. During the overnight shift June 16, Metro replaced the component as part of an upgrade of its aging track system.

Illenberg said the specific risk associated with using non-Alstom equipment is that it would require boosting the power level of the device. That, in turn, could increase the potential for a signal malfunction that could prevent the system from detecting a train on the tracks, causing a crash, according to industry sources.

Illenberg also quoted interviews that federal investigators conducted with Metro maintenance employees who voiced concerns about the compatibility of the mixed equipment. The NTSB released transcripts of those interviews this week.

"I was aware of concerns about compatibility, as you stated," Heilmann testified. Still, he said, "we did not find any reason to look for a compatibility problem."

Metro's train protection system is made up of track circuits, electrical systems embedded along the tracks that are capable of detecting the presence of a train. As trains cross the circuits, signals are transmitted down the line to following trains. The signals automatically set speeds, slowing or stopping a train so that it doesn't crash into the one in front.

Heilmann said the Fort Totten track circuit location involved in the June 2009 crash was the only location where mixed equipment was installed.

Robert Sumwalt, chairman of the NTSB hearing, said he learned of the Alstom letter Tuesday. "We will be looking at that, but I want to note the distribution list that was literally hundreds and hundreds of people," he said, declining to analyze the letter's significance to the investigation.

Illenberg said he had given a copy of the letter weeks ago to an NTSB investigator. He provided a copy to officials at the hearing.

Workers share concern

In interviews with federal investigators, Metro technicians who worked on the portion of track involved in the accident before the crash said the installation of equipment by Union Switch & Signal caused speed and power problems because it did not properly match the existing equipment, much of which they noted was 40 years old. "That's obviously mismatched," said Thomas Barcheski, a 21-year veteran of Metro at the time of the crash, according to a transcript of his interview.

Barcheski said he had asked superiors for new procedures for testing and handling the equipment but was told that there were none and that no training on it was provided by Metro. "We're not given anything," Barcheski, an automatic train control mechanic, said in his interview.

Metro officials testified Tuesday that information about new testing requirements was in the 2006 bulletin. But Alan Nabb, a senior Metro official, testified Wednesday that distribution of the bulletin to Metro's 190 technicians was "probably uneven."

Barcheski told investigators that he was not aware of those testing requirements. Moreover, employees said they were frustrated at their inability to fix problems linked to the new gear and were discouraged about trying to get the construction crews that installed the devices to return to adjust them.

"It fell on deaf ears most of the time," said Bruce Weibel, an automatic-train-control mechanic.

Use of study questioned

Under questioning, Metro officials said their highly publicized decision to sandwich the system's oldest rail cars -- like the ones involved in the June crash -- between newer ones to improve safety was not supported by engineering analyses or physical tests. Standard procedures would have required consultation with engineers. Metro officials acknowledged under oath that cars in the center of a train still suffer intense pressure in a crash. Dave Kubicek, who headed Metro's rail operation at the time, testified that the agency was responding to a lot of pressure from the public.

The Post reported in September that internal Metro documents showed the decision had been a public relations move. Metro officials said their decision was justified by an 11-year-old outside study involving a different kind of train and posted a detailed "correction" to The Post article on the agency's Web site.

In sworn testimony Wednesday, Metro engineer Mike Hiller said he disagreed with Metro's use of that study. "I could not conclusively agree that this information would support a decision on engineering to place a car into the center" of a series of rail cars, Hiller said. NTSB investigator Rick Downs asked, "Would that be a fair paper to utilize to rebut that point?" "No," Hiller responded. Metro spokeswoman Lisa Farbstein apologized to The Post after the testimony and retracted the rebuttal.

Federal investigators consider the cars to be unsafe because of their tendency to collapse during a crash.

Monitoring agency grilled

Members of the Tri-State Oversight Committee, which monitors Metro safety, testified Wednesday that they were unaware of the warning from Alstom.

Under questioning, committee members said the organization cannot penalize Metro for safety problems and has no authority to force Metro to correct hazardous conditions.

Steve Klejst, an official with the safety board, said that in recent years, the Tri-State Oversight Committee had identified scores of safety deficiencies in the subway system. But Metro routinely took years to fix the problems. Why, Klejst asked, were those problems allowed to languish?

Committee Vice Chairman Matthew Bassett replied, "We do not have any regulatory ability to sanction them."

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