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Washington Metropolitan Area Transit Authority Hi-Rail Maintenance

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Washington Metropolitan Area Transit Authority Hi-Rail Maintenance Washington Metropolitan Area Transit Authority Hi-Rail Maintenance Vehicle Strikes Two Wayside Workers Near the Rockville Station Rockville, Maryland January 26, 2010 Accident Summary Report NTSB/RAR-12/04/SUM National PB2012-916304 Transportation Safety Board NTSB/RAR-12/04/SUM PB2012-916304 Notation 8392 Adopted May 17, 2012 Railroad Accident Report Washington Metropolitan Area Transit Authority Hi-Rail Maintenance Vehicle Strikes Two Wayside Workers Near the Rockville Station Rockville, Maryland January 26, 2010 National Transportation Safety Board 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 National Transportation Safety Board. 2012. Washington Metropolitan Area Transit Authority Hi-Rail Maintenance Vehicle Strikes Two Wayside Workers Near the Rockville Station, Rockville, Maryland, January 26, 2010. Railroad Accident Report NTSB/RAR-12/04/SUM. Washington, D.C. Abstract: On January 26, 2010, about 1:40 a.m., a hi-rail vehicle—a truck or automobile that can be operated on either highways or rails—operating about 0.9 miles north of the Washington Metropolitan Area Transit Authority Rockville Metro Station struck and fatally injured two automatic train control technicians who were working on the right-of-way replacing an impedance bond between the tracks. The hi-rail vehicle was traveling down the track in the reverse gear at about 13 mph. The National Transportation Safety Board (NTSB) is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The NTSB makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Internet at <http://www.ntsb.gov>. Other information about available publications also may be obtained from the website or by contacting: National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, SW Washington, D.C. 20594 (800) 877-6799 or (202) 314-6551 NTSB publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2012-916304 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000 The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of NTSB reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. NTSB Railroad Accident Summary Report Contents Figures ............................................................................................................................................ ii Abbreviations and Acronyms ..................................................................................................... iii Executive Summary ..................................................................................................................... iv 1 Investigation and Analysis ......................................................................................................1 1.1 Accident Narrative ...................................................................................................................1 1.2 Operations Information ............................................................................................................3 1.2.1 Preaccident Events .........................................................................................................4 1.3 Postaccident Testing ...............................................................................................................10 1.3.1 Sight Distance Testing .................................................................................................10 1.3.2 Roadway Worker Visibility .........................................................................................11 1.3.3 Audible Testing ............................................................................................................12 1.3.4 WMATA Personnel .....................................................................................................12 1.4 Toxicological Findings ...........................................................................................................13 1.5 WMATA Actions Taken Since Accident ...............................................................................13 2 Safety Issues ............................................................................................................................17 2.1 Roadway Worker Protection Programs ..................................................................................17 2.1.1 Federal Government Regulation and Guidance ...........................................................17 2.1.2 State Safety Oversight..................................................................................................18 2.1.3 Prior NTSB Recommendations to WMATA Relating to Roadway Worker Protection ................................................................................................................................19 2.1.4 Adequacy of Current Roadway Worker Protection Programs .....................................20 2.2 Audible Backup Alarms .........................................................................................................21 3 Conclusions .............................................................................................................................23 3.1 Findings ..................................................................................................................................23 3.2 Probable Cause .......................................................................................................................23 4 Recommendations ..................................................................................................................24 5 Appendixes..............................................................................................................................26 5.1 Appendix A: Investigation .....................................................................................................26 5.2 Appendix B: Roadway Worker Transit Fatalities 2002–2010 ...............................................27 i NTSB Railroad Accident Summary Report Figures Figure 1. WMATA system track map, including the Red Line. .....................................................2 Figure 2. The striking hi-rail vehicle at the accident location. .......................................................4 Figure 3. Track map of WMATA Red Line, showing accident location. .......................................8 Figure 4. Aerial view of the accident location. .............................................................................10 Figure 5. Front view of a hi-rail vehicle with the upgraded lighting package. .............................15 Figure 6. Rear view of a hi-rail vehicle with an upgraded lighting package. ...............................16 Figure 7. Video screen for backup movements in a hi-rail vehicle retrofitted with the upgraded lighting package. ............................................................................................................16 ii NTSB Railroad Accident Summary Report Abbreviations and Acronyms APTA American Public Transportation Association ATC automatic train control CFR Code of Federal Regulations CM chain marker DOT U.S. Department of Transportation FRA Federal Railroad Administration FTA Federal Transit Administration MOC Maintenance Operations Center MSRPH Metrorail Safety Rules and Procedures Handbook NTSB National Transportation Safety Board OCC Operations Control Center OSHA Occupational Safety and Health Administration ROW right-of-way RWIC roadway worker-in-charge SOP standard operating procedure TOC Tri-State Oversight Committee U.S.C. United States Code WMATA Washington Metropolitan Area Transit Authority iii NTSB Railroad Accident Summary Report Executive Summary On January 26, 2010, about 1:40 a.m., a hi-rail vehicle—a truck or automobile that can be operated on either highways or rails—operating southbound about 0.9 miles north of the Washington Metropolitan Area Transit Authority Rockville Metro Station struck and fatally injured two automatic train control technicians who were working on the right-of-way replacing an impedance bond between the tracks. The hi-rail vehicle was traveling down the track in the reverse gear at about 13 mph. The safety issues discussed in this report are the following: Inadequate procedures within the Washington Metropolitan Area Transit Authority Operations Control Center for protecting roadway workers Inadequate procedures within the Washington Metropolitan Area Transit Authority Operations Control Center to coordinate work between two separate roadway worker work groups Inadequate communication between roadway worker work groups Inadequate Federal agency oversight of roadway worker policies and procedures Lack of requirements for automatic backup alarms on hi-rail vehicles The
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