NTSB: Track circuit one of many factors
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."
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.
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.
Original post: The National Transportation Safety Board (NTSB) opened 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
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