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NTSB blames '09 Metro crash on track circuit failures, negligent safety attitude

By Ann Scott Tyson
Washington Post Staff Writer
Wednesday, July 28, 2010; A01

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."

Widespread failures

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.

Metro was aware of track circuit problems as far back as 1988, the NTSB said.

The federal agency called on Metro to develop a real-time system for monitoring track circuits for problems, and Metro said it intends to have one in place by December. Metro evaluates track circuits twice a day and dispatches maintenance personnel to inspect circuits that do not detect trains. The NTSB said Metro should replace the 1,482 circuits that were built by GRS. Metro tested those circuits after the crash and found that 208 had the same malfunction that caused the crash.

With undisguised irritation, Hersman criticized Metro for not implementing many previous NTSB recommendations aimed at improving safety. "It's almost like we are talking with someone who is tone-deaf. They are not hearing it, they are not getting it and they are not addressing the problems," she said. "Our frustration is that if they don't listen this time, I am not sure what can be done."

Metro's top-to-bottom failure to prioritize safety -- exhibited by turnover and vacancies in its safety office -- is "a manifestation of the sickness that was going on inside this organization," Hersman said. "They were monkeying around."

NTSB members said safety was not made a priority by Metro's senior management or board of directors, adding that as of January, Metro board Chairman Peter Benjamin had not placed safety oversight in the board's mission statement and that former chairman Jim Graham had not heard of Metro's safety oversight organization, the Tri-State Oversight Committee (TOC). For its part, they said the TOC lacks "teeth" and cannot force Metro to be accountable for safety problems.

"This accident is a classic organizational accident," said NTSB member Robert L. Sumwalt.

Improving oversight

The NTSB recommended that the Transportation Department continue to seek authority -- proposed in legislation pushed by the Obama administration -- to regulate and provide oversight of safety at public transit systems.

Transportation Secretary Ray LaHood welcomed the recommendation.

"I thank the NTSB for its recommendation that Congress authorize the Federal Transit Administration [FTA] to enforce national transit safety standards, which could prevent future accidents," he said in a statement. "We will continue to work closely with Congress to move transit safety legislation as quickly as possible."

LaHood sent the Obama administration's bill to Congress in December 2009. Last week, Sens. Christopher J. Dodd (D-Conn.), Richard C. Shelby (R-Ala.) and Robert Menendez (D-N.J.) introduced the bipartisan bill, which would authorize the FTA to establish federal safety standards for transit systems.

"The Senate must act quickly to pass this bipartisan transit safety package that the Banking Committee has worked so hard to develop," Menendez said in a statement.

The legislation would grant the transportation secretary new enforcement authority over public transit safety, require transit agencies to establish safety plans, improve state safety oversight agencies and increase spending for public transit safety.

Impact in other cities

The NTSB also called on Alstom to conduct a comprehensive analysis of its track circuit modules to identify possible failures that could cause systems to not detect trains and to work with not only Metro but also transit agencies in Boston, Philadelphia, Los Angeles, Cleveland and Chicago to establish inspection and maintenance procedures for the circuit modules and remove any that exhibit the problem known as "parasitic oscillation" that caused the Red Line crash.

Since the accident, Alstom has been working with Metro on testing and evaluating the 1970s-era equipment and developing remedial measures for the train-control system, Alstom spokesman Tim Brown said. The company is also working with the other agencies that use the part.

The American Public Transportation Association, which is made up of public transit agencies across the country, will convene a panel of experts to review the NTSB's recommendations, association spokesman Mantill Williams said.

Kenneth Hawkins, whose brother Dennis was killed in the accident, expressed satisfaction that "hard-core facts" about the causes of the crash emerged Tuesday. But he remained dissatisfied overall.

"The question for me is: Who's going to hold [Metro] accountable?" he told reporters during a lunch break. "Who's putting his foot on the neck of" Metro?

Hawkins said the NTSB has issued recommendations in the past without much impact. "They're coming out with the truth . . . but what's really going to happen?" he asked.

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