The National Transportation Safety Board adopted recommendations Tuesday for transportation agencies nationwide,following a yearlong investigation into the deadliest crash in the history of the Washington Metro system.
Recommendations included removing track circuit modules from service – the devices that should have detected two trains were too close to each other – having the Federal Transit Administration collect and review reports from employees in all divisions of transit agencies and for the U.S. Department of Transportation to provide safety oversight of rail transportation systems.
Rail transit agencies are now supervised by states. The Obama administration is supporting a bill to have the federal government monitor rail transit.
NTSB will publish the final draft of its report in three to four weeks. Its recommendations are not binding on transit agencies.
NTSB Chairman Deborah A.P. Hersman said the safety board has a responsibility to look back at the causes and look forward for direct leadership.
“We do have an opportunity and the obligation to take every step possible to ensure that the lessons of this tragedy are well-learned and that the circumstances are never repeated,” Hersman said.
On Monday,June 22,2009,at 4:58 p.m.,two Washington Metro trains collided,killing nine people and injuring 52. Both were going in the same direction on the same track.
Metro has had six accidents in the past decade. Hersman said that “because the necessary preventive measures were not taken,the only question was when would Metro have another accident.”
The board looked into Metro's the train control system,signal and train controls and safety culture and oversight.
Ruben Payan,an NTSB senior rail investigator, explained the main problem stemmed from a parasitic oscillation,meaning errors in train detection. He said these errors might have existed at least 20 years before the accident. The crash could have been prevented by using updated testing procedures,Payan said.
“Five days before the accident,the midnight crew had the opportunity,had they done a three-shunt test to see the track wasn't functioning,” Payan explained. “The following day,the daytime crew was doing their scheduled
maintenance test,but used the old procedure,so they missed the opportunity to identify the track circuit as malfunctioning.”
NTSB also found other safety problems. For instance,there were thousands of incidents per week with malfunctions in track circuits. Metro was not testing equipment that could have identified the irregularities that led to the crash.
Another issue was Metro's overall safety culture.
The investigation found that,on the day of the accident,the train that was hit by the oncoming train was being driven in manual mode instead of automatic and was going under the speed command of 55 mph. This was considered a violation of safety rules.
The draft report said Metro's local safety oversight board was ineffective,that the Metro Board – mostly made up of local elected officials – did not provide adequate oversight,that the chief safety operator didn't have enough resources and authority and that Metro placed a low priority on addressing malfunctions in the train control systems.
Kenneth Hawkins,52,the brother of Dennis Hawkins,63,who died at the crash,attended the daylong meeting and said his family has not found normalcy in their lives. He said Metro has not done its part to acknowledge the accident was its fault.
“We have felt like we are being punished for something we didn't do,and there has been no one out there to be an advocate for us,” Hawkins said. “Those nine lives are gone,but now there are 226,000 individuals that ride the Metro every day.”
Richard Sarles,Metro's interim general manager,said Metro has no higher value than safety for customers and employees. He said Metro is issuing a contract to buy new rail cars to replace the old 1000 series rail cars that crumpled in the accident. But those cars won't be ready for use until 2013.
The system,which straddles Washington and suburban Maryland and Virginia,has allocated $30 million for safety improvements over the next three years.
“We are going to take a look at every recommendation and take each one to heart and I am going to do as much as I can to move forward,” Sarles said.