The NTSB is holding it's board meeting today on the horrific June 22, 2009 redline crash at Fort Totten. Live streaming of the meeting can be found
HERE, and is available free. So far the findings indicate a scary mix of operator error (violation of operator policy), poorly executed track sensor maintenance and poorly maintained right of way. A sad situation, but an interesting and somewhat scary look into our Metro System.
Also, the NTSB explanatory animation of the crash can be found
HERE, and help understand what went wrong.
Update 07/27/2010 @ 3:30 PM
Findings:
The collision between trains 112 and 214 was caused by a a failure of the track circuit module, causing train 214 to be undetected and allow train 112 to operate at full speed. This was caused by WMATA's failure to institutionalize their Enhanced Circuit Test created in 2005.
Contributing Factors:
1) Lack of safety culture in WMATA (safety is sacrificed over schedule)
2) Failure to effectively maintain it's track signal system
3) GRS/Alstom's failure to supply maintenance plan to prevent signal failure
4) The Tri-State Oversight Committees lack of effective oversight and lack of authority to drive change
5) The FTA's lack of federal and safety oversight
Recommandations:
FTA:
1) Seek to gain authority to enforce safety track and equipment authority more effectively,and create review reports
2) Seek toxicological reports from employees fatally injured in accidents similar to that required by the Federal Railway Association's in the Code of Federal Regulation Part 49
WMATA/WTA:
1) Provide NTSB updates on recommendations and corrective action plans created by findings above
2) Establish a program to remove and replace all old audio track signals from metro system
3) Plan to Identify and remove any signals showing signs of parasitic oscillation int he metro system
4) Remove all WMATA wayside maintenance communication stations
5) Conduct safety audit of Automatic Train Control System
6) Upgrade Preventive Maintenance System
7) Review recorded operational data to identify possible operational and safety issues
8) Non-punitive safety reporting program across company
9) Periodic Review of all Safety Audit by WTA Chairman and staff
10) Remove all 1000 series cars from service immediately, and replace them with new cars that have crash and safety features equivalent to the 6000 series metro cars
11) All train cars operating in lead car service shall be equipped with event recorders
Alstom:
1) Develop Peridioc Inspection guidelines of all GRS Audio Track Signal modules
2) Conduct a comprehensive analysis of all audio track signal modules to determine if Parasitic Oscillations are present in other models
Mass Bay, Penn Metro, Cleveland Transit, Atlanta Metro, Caifornial Metro and Chicago Transit:
1) Work with Alstom to establish GRS Audio Track Signal module periodic inspection standards to identify and remove all modules showing parasitic oscillation from service in their systems
