NTSB blames '09 Metro crash on track circuit failures, negligent safety attitude
Wednesday, July 28, 2010
Chronic track circuit failures and a negligent attitude toward safety made a catastrophic accident such as last year's fatal Red Line crash inevitable, the National Transportation Safety Board determined in its final report on the incident Tuesday, warning that the conditions that led to the crash pose a continuing risk.
The NTSB found that nearly half of the 3,000 track circuit modules Metro uses could seriously malfunction and that a quarter of its rail cars, the oldest in the fleet, offer little protection in a crash, posing an "unacceptable risk to Metrorail users." Although Metro is monitoring the problem circuits much more aggressively to manage that risk, the board recommended that the troublesome equipment and old rail cars be permanently removed as soon as possible. The NTSB has no statutory power to enforce its recommendations, which it makes without regard to cost.
Despite Metro's problems, NTSB Chairman Deborah A.P. Hersman said Washington's rail transit system, the second-busiest in the country with about 200 million passenger trips a year, remains far safer than the region's roads. Thirteen people have lost their lives on Metro trains in the 34-year history of the system, the same number killed every two weeks in automobile accidents on area roads, she said.
Metro interim General Manager Richard Sarles pledged to "carefully consider" the NTSB recommendations. The agency has set aside $30 million total in its capital budget for the next three years to carry out safety improvements. But Sarles stopped short of saying Metro would implement the recommendations and told reporters that the 1000 series cars will not begin to be replaced until 2013. Metro gave the manufacturer of the next generation of rail cars, Kawasaki, approval to begin building the replacements Monday night.
All of the problems identified by the NTSB, from specific equipment flaws to broad organizational weaknesses, were made public last year in an investigative series in The Washington Post. But the formal announcement Tuesday and the harshness of the board's language underscored the depth of the problem at Metro.
Hersman denounced Metro's failure to apply lessons from a near-crash by the Rosslyn Station in 2005, which she said could have prevented the June 22, 2009, accident near the Fort Totten Station, in which one train crashed into another, killing the driver and eight passengers and injuring scores of others.
"Metro was on a collision course long before this accident," Hersman said in an opening statement at the public meeting, attended by senior Metro leaders and safety oversight officials as well as families of the crash victims. "The only question was when Metro would have another accident -- and of what magnitude."
The NTSB report represented a scathing critique of Metro's failings leading to the Red Line crash and called for sweeping changes to bolster safety at Metro and to strengthen federal and local safety oversight of public transit nationwide.
The investigation found that the specific cause of the June 2009 accident was a failure of the automatic train-control system, which did not detect one train and instead directed another to advance toward it at full speed. Metro has known since the 2005 Rosslyn near-crash that the automatic train-control system had experienced dangerous breakdowns but had not widely implemented a track circuit test developed after that incident, the NTSB found.
If two Metro work crews that were on the scene within five days before the Fort Totten crash had used the proper test, they would have known that the track circuit was not detecting trains and they could have acted to prevent the accident.
Instead, with track circuit problems setting off thousands of alarms each week, workers at Metro's Operations Control Center were not acknowledging them, NTSB investigator Ruben Payan said. "Unfortunately, they were being ignored because of the large amount that were being reported," he said.
The NTSB also found that the manufacturer of the circuits, General Railway Signal, now owned by Alstom Signaling, did not provide a maintenance plan for the circuits that would detect the anomalies in the track circuit signal that led to the failure to detect the train.