U.S. Department of Transportation Federal Transit Agency FTA-MA-90-9005-97-1 DOT-VNTSC-FTA-97-6 SAFETY REVIEW OF WASHINGTON METROPOLITAN AREA TRANSIT AUTHORITY (WMATA) METRORAIL OPERATIONS U.S. Department of Transportation Research and Special Programs Administration John A. Volpe National Transportation Systems Center Cambridge, MA 02142 September 1997 Final Report PDF Edition April 1999 NOTICE This document is disseminated under the sponsorship of the Department of Transportation in the interest of information exchange. The United States Government assumes no liability for its contents or use thereof. NOTICE The United States Government does not endorse products or manufacturers. Trade or manufacturers' names appear herein solely because they are considered essential to the objective of this report. REPORT DOCUMENTATION PAGE Fann Appro'l8d OMB No. 0704-0188 Public reporting burden for this collection of information is estimated to average 1 hour per response, includi119 the time for reviewing instructions( searchiny existinf data sources, gathering and maintaining the data needed, and conpleting and reviewing the co lection o informa ion. Send conments r~arding this bu.rdin est\\\late or afrf. other aspect of this collection of information, including suggestions for reduc1n9 th1s burden, to Washin~ton He,c;tquarters ~~~X~~1.~ ....,Di~~t~~a~~-fg~.,l~!o~~tion Operat!~sD~~-~eJ>9rts, 1215 Jefferson_oayis Hj~~fr.... ~~!te 1 O~, ArliriJl~e>qhi::XO 1. AGENCY USE ONLY (leave blank) 2. REPORT DATE 3. REPORT TYPE AND DATES COVERED September 1997 Final Report November 1996 - July 1997 4. TITLE AND SUBTITLE 5. FUNDING NUMBERS Safety Review of Washington Metropolitan Area Transit Authority (WMATA) Metrorail Ooerations U7092/TM797 6. AUTHOR(S) Eli Gilbert, Susan Gilbert, Edmond A. Boni, and Dennis R. Newman, i' .E. 7. PERFORMING ORGANIZATION NAMECS) AND ADDRESS(ES) 8. PERFORMING ORGANIZATION Interactive Elements, Inc. * REPORT NUMBER 342 Madison Avenue New York, NY 10173 DOT-VNTSC-FTA-97-6 9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES) 10. SPONSORING/MONITORING U.S. Department of Transportation AGENCY REPORT NUMBER Federal Transit Administration Washington, DC 20590 FTA-MA-90-9005-97-1 11. SUPPLEMENTARY NOTES *under contract to : U.S. Department of Transportation Research and Special Programs Administration John A. Volpe National Transportation Systems Center Cani>ridge. MA 02142-1093 12a. DISTRIBUTION/AVAILABILITY STATEMENT 12b. DISTRIBUTION CODE This document is available to the public through the National Technical Information Service, Springfield, VA 22161 13. ABSTRACT (Maximun 200 words) A recent series of accidents and incidents at the Washington Metropolitan Area Transit Authority CWMATA) have raised concerns about the Authority's conmitment to safety as its top priority. In January 1996, a train operator was killed at an end-of-the line station when his train slid on icy tracks into parked railcars. There have also been incidents of tower supervisors misdirecting trains in yards, including an incident in which a supervisor directed a train to pass a red (stop) signal. In April 1996, WMATA disconnected the operating mechanisms for the mid-car emergency doors on approximately 100 rail cars without informing the public. The doors were disabled to allow electrical repairs to be made gradually over a two-day period without removing cars from service. Later that month, two workers were injured when their tools made contact with a live electrical cable that should have been deactivated while tracks were being repaired. On May 10, a delayed response to a fire put both firefighters and passengers at risk. This document presents a review of safety and operational issues at WMATA that have contributed to these events. It identifies historical and corporate culture issues that have affected safety performance at the Authority and presents 31 findings, many of which have been the subject of prior internal and external reviews. Recent actions to improve safety practices are also identified. 14. SUBJECT TERMS 15. NUMBER OF PAGES safety, accident investigation, Washington Metropolitan Area 92 Transit Authority (WMATA), accidents, rail transit safety 16. PRICE CODE 17. SECURITY CLASSIFICATION 18. SECURITY CLASSIFICATION 19. SECURITY CLASSIFICATION 20. LIMITATION OF ABSTRACT OF REPORT OF THIS PAGE OF ABSTRACT Unclassified Unclassified Unclassified NSN 7540·01·280-:>:>UU . Stanaai;-d Form .:YD (Rev. 2-89 Prescribed by ANSI Std. 239·~8 298-102 PREFACE A recent series of accidents and incidents at the Washington Metropolitan Area Transit Authority (WMATA) have raised concerns about the Authority's commitment to safety as its top priority. In January 1996, a train operator was killed at an end-of-the-line station when his train slid on icy tracks into parked railcars. There have also been incidents of tower supervisors misdirecting trains in yards, including an incident in which a supervisor directed a train to pass a red (stop) signal. In April 1996, WMATA disconnected the operating mechanisms for the mid-car emergency doors on approximately 100 rail cars without informing the public. The doors were disabled to allow electrical repairs to be made gradually over a two-day period without removing cars from service. Later that month, two workers were injured when their tools made contact with a live electrical cable that should have been deactivated while tracks were being repaired. On May 10, 1996, a delayed response to a fire put both firefighters and passengers at risk. This document presents a review of safety and operational issues at WMATA. It is being performed under the auspices of the Federal Transit Administration (FTA). Interactive Elements gratefully acknowledges the assistance, guidance, and comments of Jerry A. Fisher of the FTA's Office of Safety and Security, and the guidance provided by William T. Hathaway of the Volpe National Transportation Systems Center (Volpe Center). We are indebted to the management and staff of WMATA without whose cooperation this review could not have been completed. The findings and recommendations provided herein are intended as guidance for the Federal Transit Administration (FTA). They have been prepared pursuant to Contract Number DTRS57-97-P-80106 by Interactive Elements. In no event shall the FTA or Interactive Elements have any responsibility for any consequences of the use, misuse, inability to use, or reliance upon the information contained in this document; nor do they warrant the accuracy, efficacy, or applicability of its contents. iii METRIC/ENGLISH CONVERSION FACTORS ENGLISH TO METRIC METRIC TO ENGLISH LENGTH (APPAOX.. ATE) LENGTH (APPROXMATEI 1 lnc:tt (In) a 2.5 centimeter& (cm) 1 miDlmo'l•r (mm) = 0.04 lnM (In) 1 toot (It) = 30 centimetera (em) 1 centl~ (cm) = 0..4 Inch ~n) 1 y8td (~ • 0.9 tneter (m) t met9f (m) = 3.3 t..i (tt) 1 mlle (rnl) • 1.6 kl!om•ters (tcm) 1 m•"' (m) = 1,1 yw<t. (yd) t ltllometw fkl = o.s mll9 1mn AREA (APPROXIMATE) AREA fAPPflOXIMATE) 1 1 1 aquar• lneh {tq in, 1n ) • 6.5 .ciuaire cenumeteta (em ) 1 squat• (entlmeteir (om') = o.1e .aq1.1•re ~ (eq In, In'} 1 1 lqUlt"& foot (eq ft, n') • o.oe tqu•r• "*., (m ) 1 Ml*• mt"W '"''- = 1.2 aqu•re yat'dl (•q yd, )\Cf) 1 , squa;re ytrd (tq )Id. )Id~ • 0.8 9qutr• mitt• cm') t 9Q'*' kllomet• (km:) 0.4 tqilat'e mlilt (aq ml. m1 ) 1 1 = t tqU.. ml5t (sq ml, m1 ) = 2.e 1qu1r• llllom.iers (km ) 10,0009q11ar• me,.,. (m') = 1 hectare (h&) • 2.5acrM 1 acte a OA htctaite ......;. a 4 000 -·ani l'M1ara fm1l MASS . WEIGHT (APPROXIMATE) MASS • WEIGHT fAPPROXIMAT~) t ounce (ol-) = 28 gran'I$ (gm) 1 grem (gm) • 0.038 ounce (oz) t pound (lb) = 0.4$ kllogre:m (!tg) 1 kllogl'8m (tqi) • 2.2 poundt (lb) t ahol1 ton = 2:,000 pcxinct. = O..t ton.ne {1) t ton~ (t) = 1,000 ld.1ogr111M = 1.1 ehort tons lib\ ,,., VOLUME (APPROXIMATE) VOLUME (APPROXl.... TE) 1 teeapoon {lap) • 5 mllllJltera (ml) 1 milllltlW (ml) • 0.03 nuld oun~ ('It oq 1 tabl•epoo." (tbtp) • 15 mlffllhert (tnl) 111ter {I) • 2.1 pltlts tpc} 1 tluld ounc. (fl ol) = 30 mlUlltMr• (ml) 1 Ut.,(I) : 1,00qu.U(ct') 1 cup (e} = 0.24 'lttf' (I) 1 llter Ol = 0 .2$ 9f(lon (~) 1 pin1 ~ = G.47 Mttr (I) t qu•rt ~ = 0.96 MMt (I) 1 Glflon (91!) = 3.8 l!Wts (I) t cublc foot (eu ft,. rt'} • 0.03 euble meMf (In") 1 cubic mew (m~ • 38 cubic fMt 4CU tt. rt>) 1 eublO ..ar.t tcu ..... ._..,i. • 0.78cubk: metet ,,...,, 1-:uble meuir (m~ • 1.3 cuble-rdil ICU..,.. ~') TEMPERATURE tEXACTt TEMPERATURE tEXACTl ~ = ·c "'C • Jl ., QUICK INCH - CENTIMETER LENGTH CONVERSION 0 2 3 • 5 Inches [-~~...._~~--+1-~~.,.......I I I I I l ~-~-+I I 1I -~~_,I I~I cenumeters 2 3 , s 6 7 8 t 1o u 12 13 QUICK FAHRENHEIT- CELSIUS TEMPERATURE CONVERSION For more euet and °'other conversion factor&. see NBS Ml$0.. f3r'leous Pubilicatlon 288, Untts of Weights and Meaaut'M. Prlct$2.50SOCetalogNo. C1310286 ~·- iv CONTENTS Executive Summary ix I. Introduction 1 Scope of the Review 1 Methodology 2 Relationship of this Review to Other Studies 3 Organization of the Report 4 II. Summary of Conditions at WMATA at he Time of the Shady Grove Accident 5 A Brief History and System Description 5 SHIFTS IN MANAGERIAL STAFF AND FOCUS The Role of Safety in Rail Transit Organization 6 Safety at WMATA 7 REPORTING STRUCTURE STAFFING AND RESPONSIBILITIES PUBLIC AND EMPLOYEE COMMUNICATIONS The Corporate Culture at WMATA 12 ABSENCE OF RAIL OPERATIONS PERSPECTIVE AND EXPERIENCE LACK OF COMMITMENT AND UNDERSTANDING OF SYSTEM SAFETY A FAILURE OF CHECKS AND BALANCES THE CURRENT CORPORATE CULTURE III. Intelligence: Knowledge Base, Sources of Information, and Training 15 The Knowledge Base 15 Sources of Information 22 Training and Preparedness 29 IV.