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NTSB: Track circuit one of many factors

NTSB animation of crash

What this means for riders

4:35 p.m. Update: Metro Interim General Manager Richard Sarles released a statement after the crash.

"Today at Metro there is no higher value or priority than safetym," he said. "We have taken dozens of actions just in the last year, to improve safety for our customers and employees. And I pledged that we will carefully consider the comments, findings and recommendations that come forth from the National Transportation Safety Board today, and continue to work cooperatively with the NTSB just as we have in advance of today's meeting."

The rest of the statement

3:29 p.m. Update: Hersman concluded by summing up. "Yes, our recommendations are tough and set a high bar." But that is what the traveling public deserves, she said.

3:21 p.m. Update: The board has adopted the recommendations.

3:09 p.m. Update: The NTSB is now reviewing a lengthy list of recommendations, which includes recommendations for several other transit agencies across the country to identify track circuit modules similar to what caused the Metro crash and to remove them from service.

3:06 p.m. Update: Included in the probable cause is the fact that Metro failed to use a test -- developed years earlier -- that could have identified and prevented the problem at Fort Totten.

3:05 p.m. Update: The NTSB adopted about 39 findings on the cause of the Red Line crash and adopted a multifaceted probable cause statement about the crash, which includes a failure of the track circuit module designed to detect trains. The lack of safety culture, a failure to maintain the automatic train control system and the ineffectiveness of safety oversight all contributed to the accident, the NTSB said. The use of the 1000 series rail cars contributed to the severity of the crash and the loss of life, the NTSB found.

2:55 p.m. Update: Hersman: Some state oversight bodies do have appropriate authority. Refers to California and Massachusetts while the board considers an amendment to a finding on the Tri-State Oversight Committee's lack of authority.

2:48 p.m. Update: Another: Continued use of 1000 series cars is an "unacceptable risk."

2:46 p.m. Update: Proposed findings are now criticizing the board and the structure of Metro and problems with communication.

2:44 p.m. Update: Another: The Federal Transit Administration's current structure of oversight of transit systems is ineffective.

2:41 p.m. Update: Another finding would be that WMATA did not effectively distribute technical bulletins to its automatic train control technicians.

2:40 p.m. Update: Findings as proposed would say neither train operator contributed to crash.

2:35 p.m. Update: The hearing has resumed. There are 38 proposed findings.

2:30 p.m. Update: NTSB Chairman Hersman estimates the meeting will conclude within an hour.

2:14 p.m. Update: Chairman Hersman says there has been a lot of "tough talk" at the meeting but "Our recommendations are not indictments of individuals," she said.

The meeting is on a break. The board will resume at 2:25 p.m.

2:10 p.m. Update: NTSB member Rosekind commutes daily on #WMATA rail. Asks if they are moving in the right direction. Staff says they are encouraged.

Investigator Jim Ritter points out the NTSB is still investigating other accidents at Metro and will be involved in ensuring the transit agency is making changes.

2:04 p.m. Update: When looking at all alarms, #WMATA had up to 300,000 occurring every week, NTSB says.Chairman Hersman says it all becomes "noise" at some point.

1: 58 p.m. Update: Turnover at Metro, especially with chief safety officer position, is not common among transit agencies, investigator Steve Klejst says, in response to a question for Chairman Hersman about changes in the top positions at the agency.
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1:52 p.m. Update: Member Mark R. Rosekand has asked investigators to discuss how long it will take to transform the safety culture at Metro. This will take years is the conclusion.

1:48 p.m. Update: "This accident is a classic organizational accident," said NTSB member Robert L. Sumwalt.

1:36 p.m. Update: Hersman questions #WMATA's organizational structure and high turnover in the safety office.. "A manifestation of the sickness" in the organization, she said.

"If they don't listen this time, I'm not sure what else can be done here," she said.

Hersman urged Congress to address the issue.

1:30 p.m. Update: Metro was suffering from such chronic track circuit failures and safety negligence that a catastrophic accident was destined to happen, National Transportation Safety Board (NTSB) investigators found. The transit authority had at least two missed opportunities to prevent the fatal June 2009 Red Line crash, they said.

Metro's "anemic safety culture" and "layers of safety deficiencies" made a crash inevitable, NTSB Chairman Deborah A.P. Hersman said in her opening statement at a public meeting on Tuesday that will announce the probable cause of the June 22, 2009 Red Line crash that killed nine people and injured scores of others.

"Metro was on a collision course long before this accident," Hersman said.

The investigation has found that the specific cause of the accident was a failure of the automatic train control system, which did not detect one train, and instead directed another train to advance toward it at full speed.

But more troubling to investigators was the finding that Metro had known -- at least since a near-miss incident near Rosslyn at 2005 -- that the train control system had experienced dangerous breakdowns -- and had not moved aggressively to implement corrections that could have prevented the crash.

For example, NTSB investigators found that there were thousands of incidents each week in which track circuits were malfunctioning and at risk of failing to detect a train, but Metro was not performing regular tests of that could have identified and prevented the irregularity that caused the Red Line crash.

More worrisome, the NTSB found that such incidents are still occurring today, although Metro's much more aggressive monitoring of the problem has minimized - although not eliminated - the possibility of another accident.

The NTSB is likely to recommend that Metro replace all of the potentially defective track circuit components, while pushing for Metro to carry out an earlier recommendation to install a real-time system to monitor the system for failures. Metro has stated it will do that by the end of this year.

The NTSB officials also found serious problems with Metro's oldest, 1000 series rail cars, and made clear that the Metro practice known as "bellying" -- placing those cars in the middle of trains -- does not make them more crashworthy. The NTSB reiterated that Metro should accelerate the replacement of those cars.

1:26 p.m. Update: NTSB says about 1,300 alarms a day were going off at Metro.

1:22 p.m. Update: NTSB Board Member Robert L. Sumwalt criticizes the Metro board of directors and its lack of knowledge about the Tri-State Oversight Committee, the body responsible for overseeing Metro safety, prior to the accident.

"Clearly, the WMATA board of directors ... has not been keeping its eye on the safety ball," he said.

1:18 p.m. Update: Jackie Jeter, president of the union that represents most Metro employees, will be available for comment after the hearing at the NTSB Conference Center.

1:12 p.m. Update: The NTSB is exploring whether Metro gave the Rosslyn incident in 2005, where one train almost crashed into another, enough attention.

1:10 p.m. Update: An alarm going off in a garage has caused the NTSB to pause the hearing.

12:55 p.m. Update: NTSB officials are now listening to testimony about the deficiencies in safety oversight and the ineffectiveness of the Tri-State Oversight Committee.

12:45 p.m. Update: Rosslyn incident was a missed opportunity.

12:30 p.m. Update: The NTSB is now examining the safety culture at Metro.

11:25 a.m. Update: The NTSB has taken a break for lunch until 12:30 p.m.

11:20 a.m. Update: "Metro was on a collision course long before this accident," Chairwoman Deborah A.P. Hersman said in her opening statements. "As our report shows, this was not the first time Metro's safety system was compromised." Previous accidents, some of which led to employee deaths, were a prologue to the crash, she said.

"Because the necessary preventive measures were not taken, the only question was when would Metro have another accident -- and of what magnitude," Hersman said.

-- Associated Press

10:50 a.m. Update: Payan says there were widespread failures in the automatic system that is supposed to detect trains.

There were 100 track circuits that were routinely showing lack of train detection, Payan said, but those alarms were ignored by Metro

10:30 a.m. Update: NTSB investigator Ruben Payan said that there were at least two failed opportunities by Metro technicians to detect the problem that caused the Red Line crash -- a problem in the track circuit -- and prevent the crash.

Metro's rocky ride

USER PHOTOS: Share pictures of your experiences on Metro trains and buses.

TIMELINE: Take a look back at mishaps and tragedies in the system since 2009.

Original post: The National Transportation Safety Board (NTSB) tyson.gifopened its meeting Tuesday on the likely cause of the June 2009 Metro crash with board Chairman Deborah A.P. Hersman condemning Metro's "anemic safety culture" and saying "layers of safety deficiencies" made a crash inevitable.

"Metro was on a collision course long before this accident," Hersman said. "The only question was when Metro would have another accident."

Federal investigators next launched into their findings on the crash. The investigators have focused on the failure of Metro's automatic train-control system in the accident, in which one train slammed into the back of another that was stopped north of the Fort Totten Metro station in Northeast Washington. The accident killed a train operator and eight passengers, injured scores of others and caused $25 million in damage.

At the meeting Tuesday, federal investigators will present their final report. After questions and answers, the five-person board will conduct three votes: on the findings, the cause and the recommendations. It will then vote on whether to adopt the report.

The NTSB meeting Tuesday is expected to go well beyond a narrow conclusion on the causes of last year's crash, both because of the spate of accidents that have plagued Metro and possible consequences for other subway systems, according to Metro and NTSB officials.

Most accidents are less complex and involve fewer parties. But the NTSB held a wide-ranging three-day hearing in February to look at the Red Line crash and broader issues, such as how Metro identifies and corrects safety hazards and the adequacy of state and federal oversight.

-- Ann Scott Tyson

The crash | The victims | The families | The investigation | The audit
Memorials | Video Archives | Full Archives | Federal transit report | NTSB crash investigation materials

Metro outlines new safety measures

Maker of signal parts faults Metro in crash

Metro urged to add safety backup

By Michael Bolden  | July 27, 2010; 1:12 PM ET
Categories:  Metro, NTSB  
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Next: Where crash report leaves Metro riders

Comments

Coming from someone who sees all the safety releated issues in the US transportation industy, the NTSB Board chairman's "condemnation" is a pretty damming indictment of METRO, both management and employees. No wonder former GM Catoe scuttled out of town before all this came out...

Posted by: JMACSR | July 27, 2010 11:23 AM | Report abuse

Criminal charges should be next...

Posted by: yell53 | July 27, 2010 11:29 AM | Report abuse

Why has it taken the NTSB over a year to tell us what we "nonprofessionals" figured out in less than 30 days?

Posted by: ceebee2 | July 27, 2010 12:16 PM | Report abuse

I have worked around Metro and the Rail Roads. If the rail road employess acted like Metro they would be fired immediately, some fined and some in jail. Metro is not run like a rail road, if it were the safety record would be much better.

Posted by: Pilot1 | July 27, 2010 12:24 PM | Report abuse

I'm waiting for public transit apologist-in-chief Dave Alpert to post his inevitable, "Was the NTSB too hard on Metro?" column.

Posted by: WashingtonDame | July 27, 2010 12:37 PM | Report abuse

has anyone ever take notice to the people who actually repair the tracks? I don't k now if I would or can trust their k nowledge.

Posted by: masefa2005 | July 27, 2010 12:41 PM | Report abuse

The amazing thing is that Metro has already started their reverse spin on the NTSB findings by releasing a press release documenting everything they've done to improve safety since the crash...

Isn't it amazing how Metro just never quite seems to take the blame for anything? Even as the meeting is going on they are working hard (using our tax and fare dollars) to work a PR campaign to deflect the real culprit - lack of a safety culture and, with it, a lack of management oversight.

Nothing ever changes with Metro, they never accept blame, they always have some excuse, and they never consider the riders as being anything other than mindless cattle with deep financial pockets.

Posted by: mika_england | July 27, 2010 12:45 PM | Report abuse

"Clearly, the WMATA board of directors ... has not been keeping its eye on the safety ball,"

Love how it's so politically sensitive. Given their history, it would be more appropriate to say that Metro is completely blind about the "safety ball".

Posted by: mika_england | July 27, 2010 1:29 PM | Report abuse

Metro management is incompetent, and apparently impotent. Week after week there are articles outlining employee negligence and borderline criminal activity, and nobody ever gets fired. Until employees are held accountable for their actions (and inactions), Metro will be dysfunctional, and unsafe.

Posted by: 123cartoon | July 27, 2010 2:12 PM | Report abuse

GET A NEW METRO BOARD. The people running the show at the top are obviously incompetent.

Posted by: Aerowaz | July 27, 2010 2:22 PM | Report abuse

"Our recommendations are not indictments of individuals"

And there it is. The rationale for nobody at Metro being held accountable. It will be dismissed as an issue of 'culture' and not of inept or incompetent management. Nobody will be blamed, and thus, nothing will actually change.

It will take yet more unfortunate fatalities before the point is finally rammed home into legislator's brains that Metro, left to their own mismanagement, will not change their 'culture' unless forced to. The NTSB recommendations must become a forced mandate, otherwise we'll have yet another major incident sooner or later.

Posted by: mika_england | July 27, 2010 2:24 PM | Report abuse

I love all this stuff coming out of the NTSB because we all know nothing substantive will change at Metro. Except probably even higher fares.

Posted by: Aerowaz | July 27, 2010 2:49 PM | Report abuse

What is the potential culpability of Mr. Catoe, former head of Metro, in this incident? Or, are findings not directed at individuals?

Posted by: axolotl | July 27, 2010 3:19 PM | Report abuse

I watched the whole thing. I was glad to hear the driver was not blamed. Sounded like she did everything in her power to stop the train as soon as she saw the stopped train ahead. Metro should be ashamed of the way they run the system as enumerated in the final report. I wish the NTSB had the authority to enforce their recommendations.

Posted by: tbva | July 27, 2010 3:34 PM | Report abuse

The findings are not directed at any one individual. It is everyone's fault according to NTSB. Basically, the standard "safety is paramount so it is everyone's job" finding is being used.

All this means that few of the managers in Metro will actually feel that it is truly their fault. History has shown that whenever 'fault' is determined to be shared across the entire organization, the "wasn't my fault, I did my job" mentality sets in. So the organization never actually inculcates the lessons which should be learned.

So the managerial apathy that has pervaded Metro for the past decade (at least) will continue unabated.

Posted by: mika_england | July 27, 2010 3:36 PM | Report abuse

If money is the issue then Metro should discontinue service until it's resolved.

That will get Congress of it's butt.

Posted by: HillmanDC | July 27, 2010 3:41 PM | Report abuse

What the public doesn't know:

WMATA is hiding behind Sovereign Immunity granted to them by DC/MD/VA in an attempt not to pay the victim's families a red cent.

Not one case has settled.

What a kind and community friendly Metro system we have.

Posted by: concernedaboutdc | July 27, 2010 3:45 PM | Report abuse

I hope that the "comments" provided by Jackie Jeter are reported, given some of her previous ones.

Posted by: DragonofAnger | July 27, 2010 3:52 PM | Report abuse

Metro continues to refuse to retire the 1000 series cars making excuses that they need them for service. They should have been retired in 2004, after the zoo accident. If they had then last year's accident may not have been as bad. Putting them in the middle of trains is not the answer and they should not be mixed with newer railcars. As we've seen with several accidents, the 1000 series cars are unsafe no matter where they are. The 1000 series car should be retired immediately, not 4 years from now when the 7000 series car arrive.

Posted by: davinp-28 | July 27, 2010 4:09 PM | Report abuse

"WMATA is hiding behind Sovereign Immunity granted to them by DC/MD/VA in an attempt not to pay the victim's families a red cent."

Which is why Metro can warn riders of the loose tiles at the edges of some of their platforms by taking the extreme measure of placing a robust, highly immobile (unless it happens to be windy), vinyl traffic cone next to the area of concern...

Posted by: mika_england | July 27, 2010 4:12 PM | Report abuse

We deserve so much better.

Posted by: Aerowaz | July 27, 2010 4:16 PM | Report abuse

"And there it is. The rationale for nobody at Metro being held accountable. It will be dismissed as an issue of 'culture' and not of inept or incompetent management. Nobody will be blamed, and thus, nothing will actually change."

And there it is, the typical American kneejerk call for punishment and prosecution. So I suppose it would be to dispatch some sacrificial lamb off to jail to give us a false sense of security while the clock ticks down to the next catastrophe.

Posted by: Cossackathon | July 27, 2010 4:24 PM | Report abuse

Having read the whole of this report from NTSB and the comments so far sent in, I point out these facts:
'100 faulty track circuits'
'1300 alarms a day'
'WMATA had up to 300,000 alarms a week'
I must heartily endorse all the comments from mika_england, about the likelihood of the whole matter being swept under the carpet. Instead there should be the total replacement of the managing board, a ruthless streamlining of the safety organisation, a deep-seated accountability
for all the employees at all levels,an immediate scrapping of the faulty track circuits and their replacement by tried and rigorously tested equipment, and the cessation of use of the 1000 railcars.
The safety of the trains is paramount.
In view of the dreadful history of accidents, I would also endorse yell53's
comment about criminal charges.
You wouldn't find me travelling by Metro.

Posted by: davebutcher74googlemailcom | July 27, 2010 4:26 PM | Report abuse

It takes Metro a year to repair a short escalator. Is any of this surprising?

Posted by: randysbailin | July 27, 2010 4:35 PM | Report abuse

The cause of this crash was avoidable. After reading the NSTB report it is obvious that the Metro system is broken. If the proper leadership was in place years ago, maybe all the accidents could have been prevented. It truly amazes me that it would take 13 months to tell the public the obvious causes of this horrific event. They already had a history of failures and non-compliance on recommendations in regards to improving safety measures for their passengers. As always is the case, it takes a serious accident and multiple senseless deaths to make improvements in a system that has been broken for years.
If there were Senators or Congressmen killed in this accident it wouldn't have taken nearly this long to hear what was said today.
The people of the DC area deserve a safe and secure Metro system.

Posted by: wherley1 | July 27, 2010 5:12 PM | Report abuse

The NTSB is powerless. They may as well threaten to call the BOD mothers....

Posted by: askgees | July 27, 2010 5:52 PM | Report abuse

Regardless of signal failure in this crash, after watching the animation depicting the trains and esp. the section of track the crash occurred on, I fail to understand how the operator could not have noticed the train in front of her. She was going down a straight track section prior to hitting the other train in front of hers. Nevertheless, aside from her life being lost - a terrible cost to pay - no other metro employees have paid a price for their incompetence. Some have been replaced but moved on and upward in cases but no one has been taken to court for this. One other point highlighted above, this is not metro mgt alone as the source of the problem but also the union and individual track employees who are not held accountable either. In fact rarely is any employee of metro held accountable for mistakes, errors in judgement, etc. largely due to the union and a good ole boy network within Metro.

Posted by: davidmswyahoocom | July 27, 2010 5:56 PM | Report abuse

davidmswyahoocom: The animation is fairly clear that there was a curve in the track around which the train could not be seen until about 400-odd-feet in (the exact number is stated in the video). The delay between full-visual and emergency brake was about three seconds, which is to be reasonably expected. There is every evidence that the driver responded appropriately in this. And lost her life anyway.

Posted by: DragonofAnger | July 27, 2010 7:37 PM | Report abuse

Shame on the board of directors and our elected representatives that appointed them. Until we have a board of directors that ride on Metro and have family members that ride on Metro, we will continue to have a culture of lax safety and unresponsive public service at Metro. The entire board should resign for their role in this tragedy, and our elected representatives should appoint committed and involved board members to replace them.

Posted by: pato_md | July 27, 2010 9:19 PM | Report abuse

Who cares!!! My boyfriend thinks the same with me. He is eight years older than me, lol. We met online at Agelessmatch.com, a nice and free place for Younger Women and Older Men, or Older Women and Younger Men, to interact with each other. Maybe you wanna check out or tell your friends.

Posted by: jane_fark | July 27, 2010 10:02 PM | Report abuse

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