FINAL REPORT
 

Washington Metropolitan Area Transit Authority
 

(WMATA)
 

Safety Management Inspection
 

Examination Dates: March 16 to April 3, 2015 

Federal Transit Administration
 

U.S. Department of Transportation
 

1200	New Jersey Avenue, SE
 

Washington, DC 20590
 

June 17, 2015
	 	

	 	 																													 	

	 	 	

	 	 	

	 	

	 	 	

	 	 	

	 	 	 	

	 	

	 	

	 	 	

	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	

	 	 	 	

	 	 	

	 	 	

Final Report – Safety	Management Inspection

Washington	Metropolitan	Area	Transit Authority

Table of	Contents

1.0 Executive	Summary ....................................................................................................... 6
 

2.0 Introduction ................................................................................................................ 10
 

2.1 Background........................................................................................................................... 10
 

2.2 Purpose ................................................................................................................................ 11
 

2.3 Schedule and Major Activities............................................................................................... 11
 

2.4 NTSB Urgent Safety Recommendations................................................................................. 13
 

3.0 The	WMATA	System.................................................................................................... 14
 

3.1 Metrorail .............................................................................................................................. 14
 

3.1.1 Overview ............................................................................................................................... 14
 

3.1.2 Rail Vehicles and	Maintenance ............................................................................................. 15
 

3.1.3 Rail Operations Control Center ............................................................................................. 16
 

3.1.5 Signal and Train Control ........................................................................................................ 18
 

3.1.5 Traction Power and Auxiliary Power..................................................................................... 19
 

3.2 Metrorail Safety Performance............................................................................................... 20
 

3.3 Metrobus.............................................................................................................................. 22
 

3.4 Metrobus Safety Performance .............................................................................................. 23
 

4.0 FTA’s	SMI	Approach..................................................................................................... 26
 

4.1 Methodology ........................................................................................................................ 26
 

4.2 Findings and Required Actions.............................................................................................. 27
 

4.3 Findings, Required Actions and Close-out Process................................................................. 29
 

5.0 Metrorail	Findings	and	Required	Action....................................................................... 31
 

5.1 Category R-1: Inadequate Rail Operations Control Center Staffing	and	Procedures............... 31
 

Situation............................................................................................................................................. 31
 

Required	Actions................................................................................................................................ 43
 

5.2 Category R-2: Ineffective Training, Operational Testing, and	Rules Compliance Programs..... 45
 

Situation............................................................................................................................................. 45
 

Required	Actions................................................................................................................................ 52
 

5.3 Category R-3: Insufficient Track	Time for Maintenance ......................................................... 55
 

Situation............................................................................................................................................. 55
 

Required	Actions................................................................................................................................ 61
 

5.4 Category R-4: System-wide Maintenance Issues.................................................................... 61
 

Situation............................................................................................................................................. 62
 

Required	Actions................................................................................................................................ 67
 

5.5 Category R-5: Fire/Life Safety and	Emergency Preparedness................................................. 68
 

Situation............................................................................................................................................. 68
 

Required	Actions................................................................................................................................ 71
 

5.6 Category R-6: Condition	and	Performance of Tunnel Ventilation	System............................... 72
 

Situation............................................................................................................................................. 72
 

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Required	Actions................................................................................................................................ 79
 

5.7 Category R-7: Performance of Information	Management Technology ................................... 80
 

Situation............................................................................................................................................. 80
 

Required	Actions................................................................................................................................ 83
 

5.8 Category R-8: Outstanding	Items from Previous FTA Audits and	Reviews.............................. 84
 

Situation............................................................................................................................................. 84
 

Required	Actions................................................................................................................................ 87
 

6.0 Metrobus	Findings	and	Required	Action ...................................................................... 89
 

6.1 Category B-1: Concern	over the Protection	of Metrobus Operations Personnel..................... 89
 

Situation............................................................................................................................................. 89
 

Required	Actions................................................................................................................................ 91
 

6.2 Category B-2: Limited	Availability of Training	for Operations and	Maintenance Personnel.... 91
 

Situation............................................................................................................................................. 91
 

Required	Actions................................................................................................................................ 93
 

6.3 Category B-3: Inconsistent Operational Testing	and	Rules Compliance Checks...................... 94
 

Situation............................................................................................................................................. 94
 

Required	Actions................................................................................................................................ 96
 

6.4 Category B-4: System-wide Maintenance Issues.................................................................... 97
 

Situation............................................................................................................................................. 97
 

Required	Actions................................................................................................................................ 99
 

6.5 Category B-5: Lack	of Information	Management System Technology .................................... 99
 

Situation........................................................................................................................................... 100
 

Required	Actions.............................................................................................................................. 101
 

Appendix	A:	WMATA	Safety	Actions................................................................................... 102
 

Appendix	B:	NTSB Safety	Recommendations	to	WMATA .................................................... 103
 

Appendix	C:	Safety	Directive	15-1	Tracking	Matrix.............................................................. 105
 

Appendix	D:	WMATA	Organization	Chart............................................................................ 116
 

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Final Report – Safety	Management Inspection

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Acronyms

AC Alternating Current

AIM Advanced	Information	Management

APTA American	Public	Transportation	Association

AREMA American	Railway	Engineering	and	Maintenance-of-Way	Association

ASE Automotive	Service	Excellence

ATC Automatic	Train	Control

ATO Automatic	Train	Operation

ATP Automatic Train Protection

ATS Automatic Train Supervision	

BMNT Office	of	Bus	Maintenance

BOCC Bus	Operations	Control	Center

BSEH Department	of	Bus	Service	Employees'	Handbook

BUS Department	of	Bus	Service

CAP Corrective	Action	Plan

CBT Computer	Based	Training

CCTV Closed	Circuit	Television

CENI Office	of	Chief	Engineering,	Infrastructure

CENV Office	of	Chief	Engineering,	Vehicles

CFR Code	of	Federal	Regulations

CMNT Office	of	Rail Car Maintenance

CNG Compressed	Natural	Gas

COMM Communications	Branch	within	Office	of	Systems	Maintenance

CPDO Office	of	Capital	Program	Delivery

CSCM Department	of	Customer	Service,	Communications	and	Marketing

CQAL Corporate	Quality	Assurance

DC Direct	Current

DSC Departmental/Area	Safety	Committee

ELES Office	of	Elevator	and	Escalator	Services

ELM Enterprise	Learning	Management

EMI Engineering	Modification	Instruction

ESC Executive	Safety	Committee

FTA Federal	Transit	Administration

HR Department	of	Human	Resources

IRPG Office	of	Infrastructure	Renewal	Program

IT Department	of	Information	Technology

LOS Loss	of Shunt

MAP-21 Moving	Ahead	for	Progress	in	the	21st Century

MCAP Office	of	Major	Capital	Projects

MMIS Maintenance	Management	Information	System

MOC Maintenance	Operations	Center

MPLN Maintenance	Planning	and	Scheduling

MSRPH Metrorail	Safety	Rules	and	Procedures	Handbook

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Final Report – Safety	Management Inspection

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MTPD	 Metro	Transit	Police	Department

NFPA	 National	Fire	Protection	Association

NTD	 National	Transit	Database

NTSB	 National	Transportation	Safety	Board

OAP	 Operations Administrative	Procedures

OEM	 Original	Equipment	Manufacturer

PLI	 Platform	Line	Instructor

PLNT	 Office	of	Plant	Maintenance

POWR	 Power	Branch	within	Office	of	Systems	Maintenance

PRMT	 Office	of	Procurement	and	Materials

PROTECT	 Program	for	the	Response	Options	and	Technology	Enhancements for	

Chemical/Biological	Terrorism

QAAW	 Office	of	Quality	Assurance	and	Warranty

REPA	 Reliability	and	Performance	Analysis	Branch	

ROCC	 Rail	Operations	Control	Center

ROQT	 Office	of	Rail	Operations	Quality	Training

ROW	 Right-of-Way

RTC	 Rail	Traffic	Controller

RTRA	 Office	of	Rail	Transportation

RTTO	 Office	of	Train	Operations

RWIC	 Roadway	Worker	in	Charge

RWP	 Roadway	Worker	Protection

S&I	 Service	and	Inspection

SAFE	 Department	of	Safety	and	Environmental	Management

SIGAR	 System	Implementation	Gap	Analysis	Report	

SMI	 Safety	Management	Inspection	

SMNT	 Office	of	System	Maintenance

SMS	 Safety	Management	Systems

SOM	 Street	Operations	Managers

SOP	 Standard	Operating	Procedure

SRPG	 System	Renewal	Program

SSO	 State	Safety	Oversight

SSPP	 System Safety	Program	Plan

TIES	 Department	of	Transit	Infrastructure	and	Engineering	Services

TOC	 Tri-State Oversight	Committee

TRST	 Office	of	Transit	and	Structures

UPS	 Uninterruptible	Power Supply

VERSE	 Vertical	Rail	Stiffness	Equipment

WMATA	 Washington	Metropolitan	Area	Transit	Authority

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Final Report – Safety	Management Inspection

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1.0 Executive Summary 

Over the last decade, the Washington Metropolitan Area Transit Authority (WMATA) has 

experienced several serious rail accidents. Among these is the June 22, 2009, collision of two 

Metrorail trains near Fort Totten station, resulting in the death of eight passengers and a train 

operator and injuring 52 others, and the January 12, 2015, electrical arcing incident near the 

L’Enfant Plaza underground station that produced toxic smoke conditions resulting in one 

passenger fatality and 90 injuries. Over the last decade, seven collisions occurred with WMATA 

workers on the rail transit right-of-way (ROW), resulting in nine fatalities and several serious 

injuries. 

In response to concerns regarding this safety performance, the U.S. Department of 

Transportation’s Federal Transit Administration (FTA) conducted an organization-wide Safety 

Management Inspection (SMI) of the WMATA rail and bus transit systems. Utilizing new safety 

authority established by the Moving Ahead for Progress in the 21st Century Act (MAP-21) in 

2012, the FTA SMI evaluated WMATA’s operations and maintenance programs, safety 

management capabilities, and organizational structures to identify areas where the agency must 

further enhance its conformance with its own rules and procedures, FTA’s existing regulations, 

and FTA’s Safety Advisories to reduce risks and make improvements for the safety and wellbeing of its passengers and employees. 

FTA finds that over the last five years, WMATA has implemented new management initiatives 

and programs to address safety concerns, made advancements in many areas, and improved its 

safety culture. However, the SMI identified organizational deficiencies and operational concerns 

that continue to limit the agency’s effectiveness in recognizing and resolving safety issues and 

hazards. In key areas, WMATA’s organization is not effectively balancing safety-critical 

operations and maintenance activities with the demand for passenger service. 

For Metrorail, the FTA SMI determined that WMATA work crews do not have sufficient access 

to the rail ROW to perform critical inspection, testing and maintenance activities. Also, for some 

of Metrorail’s more complicated technical systems, shared responsibilities for maintenance 

inspections and repairs, training, and operational testing are not always well managed, leaving 

one department’s top safety priorities unaddressed by another department with different focus 

areas and considerations. In addition, the SMI identified clear deficiencies in the availability, 

quality and performance of technical training, refresher training, and rules compliance and 

operational testing activities. Poorly functioning and poorly utilized information management 

systems and technology also limit the effectiveness of WMATA’s training, rules checks and 

operational testing, and maintenance programs and activities. 

Perhaps most significantly, the FTA SMI found serious safety lapses in the Rail Operations 

Control Center (ROCC) related to the training and certification of rail traffic controllers; the 

ROCC structure, organization and staffing; the availability of checklists, procedures, manuals 

and tools; the quality of the radio system and radio communications; and the performance of the 

Advanced Information Management system to visually display and monitor the status of the rail 

transit system. Collectively, these issues significantly impact the ability of the Metrorail system 

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to schedule and conduct maintenance work, to manage abnormal and emergency events, and to 

ensure the safety of trains and personnel on the ROW. 

While not rising to the level of seriousness found in rail operations, the SMI identified a few 

concerns in the Bus Operations Control Center regarding the lack of manuals, documented 

checklists and procedures for bus dispatchers, and a general level of informality in bus radio use 

and communications. The SMI also determined that WMATA’s bus operating and maintenance 

departments have unmet training needs, and do not generally conform with all requirements 

specified in rules compliance and operations testing programs, including annual refresher 

requirements. Areas were identified where automated systems could greatly improve safety 

processes, and where specific types of maintenance inspections and reviews would benefit fleet 

safety performance. FTA also found that Metrobus employees at all levels of the organization 

identified their most significant safety concern as WMATA’s ability to protect bus operations 

personnel from violent, disgruntled, or disruptive passengers and members of the public. 

As a result of this SMI, FTA issues 44 safety findings in eight categories regarding WMATA’s 

Metrorail system and 10 safety findings in five categories regarding WMATA’s Metrobus 

system. To ensure that FTA’s SMI findings are resolved, FTA is issuing Safety Directive 15-1 to 

WMATA that identifies 78 distinct corrective actions to be completed by Metrorail and 13 

distinct corrective actions to be completed by Metrobus. 

WMATA Metrorail System 

Categories of Metrorail System Finding Number of Findings and Required Actions 

• Category R-1: Inadequate Rail Operations Control 

Center Staffing and Procedures 

14 Findings and 21 Required Actions 

• Category R-2:Ineffective Training, Operational Testing 

and Rules Compliance Programs 

8 Findings and 22 Required Actions 

• Category R-3: Insufficient Track Time for Maintenance 4 Findings and 4 Required Actions 

• Category R-4: System-wide Maintenance Issues 7 Findings and 7 Required Actions 

• Category R-5: Fire/Life Safety and Emergency 

Preparedness 

2 Findings and 7 Required Actions 

• Category R-6: Condition and Performance of Tunnel 

Ventilation System 

3 Findings and 4 Required Actions 

• Category R-7: Performance of Information 

Management Technology 

4 Findings and 8 Required Actions 

• Category R-8: Outstanding Items from Previous FTA 

Audits and Reviews 

2 Findings and 5 Required Actions 

Total 44 Findings and 78 Required Actions 

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Final Report – Safety	Management Inspection

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WMATA Metrobus System 

Categories of Metrobus System Finding Number of Findings and Required Actions 

• Category B-1: Concern over Protection of Metrobus 

Operations Personnel 

1 Finding and 2 Required Actions 

• Category B-2: Limited Availability of Training for 

Operations and Maintenance Personnel 

2 Findings and 2 Required Actions 

• Category B-3: Inconsistent Operational Testing and 

Rules Compliance Checks 

3 Findings and 4 Required Actions 

• Category B-4: System-wide Maintenance Issues 2 Findings and 2 Required Actions 

• Category B-5: Lack of Information Management 

System Technology 

2 Findings and 3 Required Actions 

Total 10 Findings and 13 Required Actions 

WMATA will have 30 days to respond to FTA’s Safety Directive, to provide additional 

information for consideration, and to propose any equivalent alternate actions. Sixty days 

thereafter, WMATA must submit a tracking matrix to FTA that identifies the specific actions 

that will be performed to address each required element specified in this Safety Directive; the 

milestone schedule for completing corrective action; the responsible parties for action and their 

contact information; and the verification strategy for ensuring the completion of required work. 

FTA will review and approve WMATA’s work plans, and will monitor the agency’s progress in 

resolving each finding and required action. FTA will conduct monthly meetings with WMATA 

to review progress until such time as FTA determines that these meetings are no longer needed 

or may be conducted with less frequency. 

FTA also will consult with the Tri-State Oversight Committee (TOC), the entity responsible for 

managing the federally required State Safety Oversight Program for the Metrorail system, on the 

final review and approval for WMATA work plans addressing Metrorail activities. In addition, 

FTA is asking the WMATA Board of Directors to closely monitor the time and resources made 

available for the operations and maintenance departments to conduct safety critical inspection, 

testing, training, and repair activities on the Metrorail rail system. WMATA participated fully in 

the SMI and FTA anticipates that cooperation to continue through the completion of all 

corrective actions in response to this report. 

In addition, in support of the SMI, FTA performed a Safety Management System (SMS) Gap 

Analysis to evaluate WMATA’s approach to safety management practices as they relate to a 

fully mature SMS. The SMS Gap Analysis was not an exercise in safety compliance. SMS is a 

management approach adopted by FTA that ensures each public transportation agency has the 

necessary organizational structures, accountabilities, policies, and procedures in place to direct 

and control resources for safety management. SMS is not a requirement in the public 

transportation industry. Thus, this cooperative effort with WMATA serves as a tool for 

continuous improvement in WMATA SMS development and implementation activities. 

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Final Report – Safety	Management Inspection

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SMS has four levels of maturity: Initiating, Planning, Implementing, and Managing and 

Monitoring. The SMS Gap Analysis identified an overall WMATA SMS maturity level between 

Planning and Implementing with some areas at the Managing and Monitoring level. SMS is new 

to the public transportation industry and may take a transit agency two to four years to reach the 

full maturity level depending on its size and complexity. To further advance its SMS efforts, 

WMATA has accepted an FTA invitation to participate in a SMS pilot program. 

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Final Report – Safety	Management Inspection

Washington	Metropolitan	Area	Transit Authority

2.0 Introduction 

This final report documents the results of the Safety Management Inspection (SMI) performed 

by the Federal Transit Administration (FTA) for the Washington Metropolitan Area Transit 

Authority (WMATA) Metrorail and Metrobus systems. Conducted with the full participation of 

WMATA’s state safety oversight agency, the Tri-State Oversight Committee (TOC), FTA’s SMI 

evaluated WMATA’s operations and maintenance programs, safety management capabilities, 

and organizational structures to assess WMATA’s compliance with its own requirements, 

procedures, rules and programs to ensure the safety of the public, WMATA’s employees, and 

WMATA’s system infrastructure. 

2.1 Background 

WMATA manages the second largest heavy rail transit system (Metrorail) and the sixth largest 

bus network (Metrobus) in the United States. WMATA provides 85 percent of all public 

transportation in the national capital region, serving a geographic area of 1,500 square miles and 

5 million residents. WMATA’s Metrorail system averages approximately 730,000 weekday 

passengers and Metrobus carries approximately 465,000 weekday passengers. 

FTA is a major funding partner in the WMATA system, providing between $250 million and 

$500 million per year through a range of grant programs, such as Section 5307 Formula funding 

for capital assistance, the Section 5309 Fixed Guideway Modernization program, and the recent 

American Recovery and Reinvestment Act provisions devoted to transit capital projects and 

preventive maintenance. In addition, beginning in 2010, the U.S. Department of Transportation 

provided the first of 10, $150 million grants authorized through the Passenger Rail Investment 

and Improvement Act to address critical safety needs at WMATA, such as replacing WMATA’s 

aging 1000 series rail cars with more crashworthy and energy efficient vehicles. In all, the 

Federal government provides approximately 20 percent of WMATA’s total budget. This level of 

funding does not count FTA’s $900 million commitment to the Dulles Corridor Silver Line 

project, being constructed by the Metropolitan Washington Airports Authority (MWAA). 

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Over the last decade, WMATA has experienced several serious accidents, including the collision 

of two Metrorail trains on June 22, 2009, near Fort Totten station, which resulted in the deaths of 

eight passengers and a train operator, and injured 52 others. Between 2005 and 2010, WMATA 

also lost eight workers in six collisions with trains and equipment on the rail transit right-of-way 

(ROW). Since 2010, in partnership with FTA, the TOC, and in response to recommendations 

from the National Transportation Safety Board (NTSB) and increased scrutiny from the Virginia, 

Maryland and District of Columbia Congressional delegations, WMATA enhanced its safety 

focus and improved safety performance. 

As a result of these initiatives and activities, many of which were reviewed and approved by 

FTA and the TOC, WMATA’s Metrorail system experienced no passenger, employee or 

contractor fatalities for 44 straight months (February 2010 through October 2013). For both 

Metrorail and Metrobus, employee injuries fell from 5.19 per 200,000 hours worked in calendar 

year 2011 to 4.2 per 200,000 hours worked for calendar year 2014. Passenger injuries fluctuated 

from a low of 1.68 injuries per million passengers in calendar year 2012 to 1.96 injuries per 

million passengers in calendar year 2014, allowing WMATA to maintain its goal of less than 2 

injuries per one million passengers for four straight years. However, on October 6, 2013, two 

WMATA employees were injured and a contractor was killed when they were struck by a 40-

foot section of rail during an emergency evacuation of work zone in a tunnel near Union Station. 

During calendar year 2014, the number of fires and smoke events requiring suppression on the 

WMATA Metrorail system almost doubled from 15 in 2013 to 29 by the end of December 2014. 

On January 12, 2015, an electrical arcing incident resulted in toxic smoke conditions that caused 

one passenger fatality and injured 90 others. 

2.2 Purpose 

In response to concerns regarding this recent safety performance, the FTA conducted an SMI of 

the WMATA Metrorail and Metrobus transit systems, utilizing new safety authority established 

by the Moving Ahead for Progress in the 21st Century Act (MAP-21). FTA’s SMI evaluated 

WMATA’s operations and maintenance programs, safety management capabilities, and 

organizational structures to identify areas where the agency must further enhance its 

conformance with its own rules and procedures, FTA’s existing regulations, and FTA’s Safety 

Advisories, to reduce risks and make improvements for the safety and well-being of its 

passengers and employees. 

2.3 Schedule and Major Activities 

After formally notifying WMATA on February 4, 2015, FTA worked closely with WMATA to 

complete an extensive document request and to schedule interviews, field observations, 

inspections, and demonstrations regarding the performance of key equipment, information 

management systems and technology. FTA conducted the SMI for both WMATA’s Metrorail 

and Metrobus systems between March 16 and April 3, 2015. 

To conduct the SMI, FTA assembled 10 teams comprised of over 35 technical, safety and transit 

operations experts to complete a comprehensive assessment. FTA’s SMI team reviewed and 

assessed: 

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•	 WMATA’s track, traction power, signal and train control, ventilation, physical plant, and 

rail and bus vehicle inspection, testing, and maintenance programs; 

•	 WMATA’s rail and bus operations control centers; 

•	 Radio and visual display systems used to support and monitor rail and bus operations; 

•	 WMATA’s roadway worker protection program and employee safety programs; 

•	 Formal and informal communication regarding maintenance and safety issues at all levels 

of the organization; 

•	 Initial and refresher training programs for operations and maintenance employees; 

•	 Fatigue management and work scheduling practices; 

•	 Rules compliance and operational testing programs, and the quality of supervision; 

•	 WMATA’s information management and data analysis capabilities; and 

•	 Plans, procedures, and training programs for managing emergencies in service, and 

ensuring the readiness of front-line personnel and local emergency responders. 

Throughout the course of the SMI, FTA’s experts reviewed relevant records, documents, plans, 

policies, and procedures; conducted field inspections and made observations at various locations 

on the WMATA system by riding trains, other on-track equipment and buses, by walking along 

tracks and in facilities and observing work, by conducting independent inspections of completed 

work orders at a range of rail and bus facilities and installations, and by interviewing over 300 

WMATA employees at all levels of the agency, including executive management, technical 

management, superintendents, assistant superintendents, managers, supervisors, front-line 

employees and union representatives. 

FTA’s SMI team members also attended WMATA safety committee meetings at every level, 

completed Level 1 Roadway Worker Protection (RWP) training and certification, and reviewed 

several on-going training classes and training materials. FTA’s experts spent one week focused 

on WMATA’s Rail Operations Control Center (ROCC) and several days in WMATA’s Bus 

Operations Control Center (BOCC) observing communications, the performance of radio and 

visual display systems, the documentation and transmission of information and calls coming into 

the ROCC and BOCC, and the overall quality of radio communications to manage the transit 

system. 

Finally, FTA’s experts carefully assessed the tools and systems used by WMATA employees to 

manage, schedule and plan work; to monitor the performance and quality of work; and to 

establish indicators and targets to direct specific maintenance and operations activities, 

considerations and coordinated actions. 

During the SMI, FTA teams met regularly with WMATA leadership and staff, to brief them on 

FTA’s findings. FTA also conducted a factual review of the contents of this report with 

WMATA’s technical leadership. Over the course of the SMI, WMATA’s executive team also 

updated FTA on the status of 14 initiatives newly underway to improve the safety of WMATA’s 

operations and procedures since the January 2015 incident. Appendix A lists these activities. 

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2.4 NTSB Urgent Safety Recommendations 

On February 11, 2015, the NTSB issued a series of Urgent Safety Recommendations to 

WMATA, the American Public Transportation Association (APTA), and FTA to address 

concerns stemming form their investigation into the January 12, 2015 electrical arcing incident at 

L’Enfant Plaza station. These urgent recommendations, R-15-7 through R-15-12, related to the 

need for improvements in the performance of tunnel ventilation systems, the availability and 

quality of written procedures to address smoke and fire events in tunnels, compliance with 

industry best standards, including those issued by the National Fire Protection Association 

(NFPA), and training and emergency preparedness programs. 

On June 8, 2015, the NTSB also issued safety recommendation R-15-25 to WMATA, urging the 

Metrorail system to promptly develop and implement a program to ensure that all power cable 

connector assemblies are properly constructed and installed in accordance with the agency’s 

engineering design specifications, including the weather tight seals that prevent intrusion by 

contaminants and moisture. The NTSB also noted that there are other components in the third 

rail power distribution system that can be susceptible to electrical arc tracking and short circuits, 

and that WMATA’s programs and maintenance procedures to address these issues are being 

examined as part of the ongoing L’Enfant Plaza accident investigation 

While FTA’s SMI is separate from the NTSB investigation, FTA incorporated elements of 

NTSB’s Urgent Safety Recommendation R-15-7 to FTA into field activities, interviews, and 

document reviews. During the week of March 30, FTA’s experts spent several days focused on 

the state of repair of WMATA’s tunnel ventilation system; the procedures regarding the 

inspection, maintenance and repair of those systems; the level of oversight and monitoring 

regarding the performance of this work; the interfaces required across departments to ensure the 

effective repair and functioning of all tunnel ventilation system components; and necessary 

coordination with the ROCC. 

While the NTSB’s Safety Recommendation R-15-25 was issued after the conclusion of the onsite portion of FTA’s inspection, FTA did review maintenance practices and procedures for 

WMATA’s third rail power distribution system as part of the SMI. 

Appendix B addresses the status of NTSB recommendations made to WMATA. 

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3.0 The WMATA System 

WMATA operates the second largest heavy rail transit system (Metrorail) and the sixth largest 

bus network (Metrobus) in the United States. WMATA provides 85 percent of all public 

transportation in the national capital region, serving a geographic area of 1,500 square miles and 

five million residents, across the jurisdictions of the District of Columbia, Maryland 

(Montgomery and Prince George's Counties), and Northern Virginia (Alexandria City, Arlington 

County, and Fairfax County). 

3.1 Metrorail 

3.1.1 Overview

WMATA’s Metrorail system operates six lines (Blue, Green, Orange, Red, Silver and Yellow) 

through 118 miles of track and 91 stations using a fleet of approximately 1,100 vehicles in seven 

different series (1000 through 7000). Each weekday Metrorail provides approximately 730,000 

passenger trips. Typical service hours are 5:00 a.m. through midnight on Monday through 

Thursday; 5:00 a.m. on Friday morning through 3:00 a.m. on Saturday morning; 7:00 a.m. 

Saturday morning through 3:00 a.m. on Sunday; and 7:00 a.m. on Sunday morning through 

midnight. 

Metrorail stations are subsurface, at grade and elevated construction with multiple entry/exit 

points to street level. Additional exits, escalators, stairs and elevators provide vertical circulation 

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between street, fare collection and platform levels. In total, WMATA maintains 613 escalators 

in the operating system and 275 elevators in stations and parking facilities. Some stations have 

adjacent parking facilities, pick-up/drop-off areas and/or bus pull-in areas to accommodate 

patrons arriving by automobile or by bus. 

Depending on special events and other considerations, WMATA puts between 125 and 144 

trains in service each day, using a combination of 6-car and 8-car trains. Beginning on April 14, 

2015, WMATA placed its first 8-car train comprised entirely of its new 7000-series vehicles, 

manufactured by Kawasaki Rail Car, Inc., into service. At the time of FTA’s SMI, WMATA had 

ordered 528 of these new rail cars, enough to replace all 1000- and 4000-series cars and expand 

the size of the Metro fleet by 128 cars. The composition of WMATA’s rail fleet at the time of the 

SMI appears below: 

Years Introduced Number of Rail Cars Owned Rail Cars Available for 

Service 

Series 

1975-1980 300 278 1000 

1983-1988 366 358 2000 and 3000 

1992-1994 100 100 4000 

2001-2004 192 184 5000 

2006-2008 184 184 6000 

2015 8 8 7000 

Total 1,142 1,112 n.a. 

3.1.2 Rail Vehicles and	Maintenance

WMATA uses seven Service and Inspection (S&I) Shops located throughout the system to 

provide routine maintenance for WMATA’s rail vehicles. WMATA also has tracks for overnight 

storage of vehicles at two other locations. The major repair facilities for rail car and equipment 

overhaul, extensive modifications, wheel cutting, and spare parts storage to support the Metrorail 

system are located at the Brentwood and Greenbelt Yards. 

All shops with the exception of Branch Avenue have the capacity for providing wheel truing. 

With the construction of Dulles Corridor Rail Extension, a new storage yard with heavy repair 

and overhaul shop will be constructed and located in the Dulles Corridor. New rail car 

acceptance and preparation are accomplished at the Greenbelt Yard, where WMATA will 

complete a new test track and commissioning facility for the 7000-series vehicles later this year. 

WMATA’s Office of Rail Car Maintenance (CMNT) Preventive Maintenance Program is 

comprised of progressive inspection, servicing and cleaning activities needed to meet the 

inspection requirements defined by the vehicle manufacturer and WMATA’s vehicle engineers. 

An average of 76 rail cars are needed to conduct the scheduled maintenance program on a daily 

basis. 

Because not all preventive maintenance can be done during off peak and non-revenue hours, 

vehicles must be withdrawn from revenue service for some portions of the Preventative 

Maintenance Program. Inspection and preventative maintenance occurs seven-days-a-week in 

three shifts. In addition to these standard preventative maintenance staff hours, WMATA 

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employs mechanics to respond to unscheduled maintenance issues and failures in the field and 

during off-peak hours. 

WMATA inspects all vehicles on a daily basis before they enter service, with more in-depth 

inspections every 30 (Intermediate Inspection), 90 (A Inspection), 180 (B Inspection), or 360 

days (C Inspection). The inspection procedures identify a list of parts that must be checked to 

perform within specifications, or the vehicle is not released for service. The total time needed to 

perform an inspection varies from half an hour for daily inspections, to 36 total hours for Type C 

inspections. Additional time may be required for part replacement or repair activities. 

WMATA’s new 7000 series vehicles will be inspected and maintained on a mileage basis. 

WMATA’s Office of Chief Engineer Vehicles (CENV) supports CMNT. CENV provides 

technical support for vehicle procurement and contractor selection for rail car vehicles. CENV is 

also responsible for the development and maintenance of configuration control specifications and 

historical databases for rail car vehicles and configuration controlled documents for rail car 

maintenance personnel. 

Within CENV is the Reliability and Performance Analysis Branch (REPA) that monitors and 

reports on reliability and performance of the rail car fleet. A second branch with CENV is the 

Maintenance Planning and Scheduling (MPLN) branch that provides technical support to CMNT 

and other departments for the purpose of implementing WMATA’s overall preventive and 

corrective maintenance programs. MPLN ensures that every asset, fixed or rolling stock is 

properly and effectively maintained through preventive and corrective maintenance and that all 

records and data pertaining to the assets are accurate, reliable and controlled. 

WMATA’s Quality Assurance and Warranty (QAAW) is another support component of the 

CMNT team. QAAW has the responsibility to perform quality control inspection, testing, as well 

as identifying and resolving problems relating to personnel performance, equipment and 

procedures. QAAW inspectors observe, inspect and document non-compliance of equipment 

procedures and employees’ actions against approved and established standards. 

3.1.3 Rail Operations Control Center

Train control supervision for the entire rail transit system is performed through the Rail 

Operations Control Center (ROCC) located at the Carmen E. Turner Maintenance and Training 

Facility in Maryland. WMATA’s ROCC is staffed 24 hours per day, seven days per week. Train 

operating rules and standard operating procedures (SOPs) for all WMATA Metrorail mainline 

routes are set forth in the Metrorail Safety Rules and Procedures Handbook (MSRPH). 

The ROCC directs Metrorail traffic using an Advanced Information Management (AIM) system 

to provide a visual display and alarm status monitoring for train positions, switch positions, 

signal status and malfunctions, and status of support systems such as ventilation, drainage, fire 

and intrusion alarms, traction power system status, and drainage pumping station alarms. Rail 

Traffic Controller or RTCs must respond to alarms and notifications from the AIM system to 

manage service and ensure the proper functioning of equipment and systems. 

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The ROCC has direct communication via radio, telephone and/or public address with the 

following: 

•	 Train operators and passengers, 

•	 Station managers and passengers in stations, 

•	 Office of Track and Structures and the Office of System Maintenance (including 

Automatic Train Control, Communications, Power and Automatic Fare Collection), 

•	 Office of Rail Car Maintenance and Office of Plant Maintenance, 

•	 Road, terminal, and yard tower supervisors, 

•	 Local fire/rescue communications centers, 

•	 Metro Transit Police Department and local police, 

•	 Bus Operations Control Center, 

•	 Control towers of common corridor railroads, and 

•	 WMATA’s Department of Safety and Environmental Management (SAFE). 

WMATA’s communication systems include: 

•	 Comprehensive Radio Communications System, 

•	 Conventional Mobile Radio Systems, 

•	 Metro Transit Police Mobile Data Terminals, 

•	 Public Safety Radio System Interfaces, 

•	 Public Safety System Distributed Antenna System, 

•	 Metrorail Station Closed Circuit Television (CCTV) System, 

•	 Metrorail Station Digital Video Recorder System and Parking Garage CCTV, 

•	 Fire and Intrusion Alarm Systems and Yard Security System, 

•	 Public Address Systems, Integrated Intercommunications System, Passenger Emergency 

Response System, and Passenger Information Display Systems, 

•	 Environmental Monitoring Systems (Veeder Root/Gas Tank Leak Detection Systems) 

and Methane Gas Detection Systems, and 

•	 Program for the Response Options and Technology Enhancements for 

Chemical/Biological Terrorism (PROTECT) system. 

A back-up computer provides redundancy, and automatically activates if the primary control 

computer malfunctions. Two diesel generators provide standby power if commercial power is 

lost. In addition, an Uninterruptible Power Supply (UPS) that will provide thirty minutes of 

emergency power supply for critical ROCC communication equipment and computer functions. 

The Maintenance Operations Center (MOC), also part of the ROCC, is responsible for 

coordinating and monitoring all personnel and equipment responding to emergencies, revenue 

train delays, unusual occurrences, equipment, and facility malfunctions having the potential to 

disrupt or affect revenue service on the rail and bus systems. 

WMATA’s Jackson Graham Headquarters contains a back-up ROCC, which served as the 

Metrorail’s original control center before the new Carmen E. Turner facility was constructed. 

WMATA’s Metrorail system can be operated from either location. 

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3.1.5 Signal and Train Control

WMATA’s train operations are governed by an automatic train control (ATC) system for train 

movements in both directions on two main tracks. The train control system was designed during 

Metrorail’s original construction in the early 1970’s. In many locations throughout the system, 

original train control equipment continues to be utilized, though rehabilitation and upgrade 

programs are underway to replace ATC components. The system employs “go/no-go” signals 

located at interlockings and speed read-outs to direct train operation. Interlockings are places 

where tracks join together and include track switches, associated signals and the control 

machinery that connects them to enable their operation and ensure safe operation. 

Metrorail mainline routes are divided into blocks between the terminal stations at the ends of 

each route. Each block is checked for train occupancy utilizing audio frequency track circuits. 

Tuned impedance bond devices are installed at block boundaries. The impedance bonds transmit 

onto the rails the coded signals generated in the train control room that are used to detect the 

presence of a train in a block and to signal speed commands to trains. 

A train operator can carry out train operations on Metrorail mainline routes in either automatic 

train control or manual control. ATC consists of three control subsystems; automatic train 

protection (ATP), automatic train supervision (ATS) and automatic train operation (ATO). 

Manual control can override ATS and ATO but does not override ATP. After the 2009 Fort 

Totten collision, WMATA suspended automatic train operations. After WMATA completed an 

extensive safety analysis and engineering evaluation of the performance of the ATC system, and 

replaced all of the older track circuits subject to the types of “parasitic oscillations” that caused 

the 2009 collision on the Red Line, automatic train control was recently restored to the Red Line 

during peak hour service. The rest of the system remains in manual operations. 

Whether in manual or automatic operations, audio frequency track circuits provide track 

occupancy detection and speed commands. Audio frequency track circuits are electrical systems 

capable of detecting the presence of a train on the tracks and providing commands to such trains 

regarding their speed and behavior. Interlocking locations are primarily operated automatically; 

but the operation of the interlocking can be requested remotely by ROCC or from a local control 

panel in field train control rooms. 

In automatic or manual, WMATA’s ATP subsystem is designed to provide protection against 

collisions and over-speed conditions through the automatic block signaling system. Effective 

analysis and maintenance of the ATC system is critical to ensure the continued safe operation of 

the system. The ATP subsystem also provides control of interlockings, route security through 

interlockings and control of train door operation. 

When in automatic modes, the ATO subsystem performs the functions of accelerating the train to 

running speed, regulating the train running speed, and stopping the train at proper positions at 

stations. The ATS subsystem controls and supervises the routing and scheduling of the trains. 

The ATS subsystem also supervises and controls the transit system mechanical support and 

electrical power facilities. 

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The ATC unit within the Office of Systems Maintenance (SMNT) maintains Metrorail’s ATC 

system in conformance to WMATA’s testing, inspection and maintenance procedures, including: 

• ATC-1000 Instructions for Testing and Inspection of ATC Apparatus And Systems, 

• ATC-2000 System Integrity Maintenance Practices, and 

• ATC-3000 Preventative Maintenance and Technical Procedures Manual. 

3.1.5 Traction Power and Auxiliary Power

The 750 volts, direct current (DC) traction power system provides the power source for vehicle 

propulsion. The traction power system includes contact and running rails, associated conductor 

system, with insulators supporting the contact rail, power substations and tiebreaker stations 

including transformers, rectifiers and switchgear for conversion and supply of power to the 

contact third rail system. Each segment of contact third rail can be supplied by adjacent power 

substations, and is supplied by separate power company substations, wherever practicable, for 

additional reliability. At many places in WMATA rail system, wide gaps in the third rails are 

provided to support track access and wayside equipment placement. Jumper cables bridge these 

gaps like extension cords, ensuring that 750 volts is available to the third rails, providing power 

to trains. 

To enhance capacity, WMATA is currently making a series of improvements to the tractionpower system to allow the deployment of eight-car trains. Eight-car trains increase the power 

requirements of each train and, therefore, the load put on the traction power system increases. 

Additional transformers, rectifiers, breakers, track feeder cables and negative return cables must 

be installed to support the power necessary to operate eight-car trains. These upgrades are 

required to ensure 8-car trains can operate without the risk of an overload to the power system, 

which could cause damage to the power equipment, cabling and/or trains. 

A 480/277 volts alternating current (AC) auxiliary power system provides for lighting, heating, 

ventilation, air conditioning, escalators and elevators, communications, train control systems, 

fare collection equipment, emergency power systems, illuminated signs, clocks, alarms, station 

CCTV, public address (PA) systems, and pumping stations. Additionally, emergency power is 

provided from an uninterruptible power supply (UPS) battery system to prevent loss of critical 

lighting, Automatic Train Control, and communications in case of a complete loss of AC power. 

There are 74 permanent generators at key stations and facilities, 19 mobile (trailered) generators 

and 13 portable generators to provide power for safety critical equipment in the event of power 

loss. 

The Power (POWR) branch within SMNT is responsible for the maintenance of all WMATA AC 

and DC power electrical facilities and equipment to ensure power is available for all passenger 

stations, trains, rail yards, chiller plants, tunnels, fan shafts, bus facilities and support for Start-up 

activities. Power personnel inspect, modify, overhaul, test and repair power distribution 

switchgear, lighting systems, associated electrical equipment and cables. 

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3.2 Metrorail Safety Performance 

An analysis of WMATA’s safety event, injury and fatality data from annual submissions 

collected by FTA through the state safety oversight (SSO) program for calendar years 2008 to 

2013 shows generally improving safety performance for WMATA’s Metrorail system. Total 

safety events, fatalities and injuries all fell at WMATA since 2010, while generally increasing 

for most of WMATA’s peers and the entire heavy rail transit industry during the same period. 

Preliminary data reviewed from the FTA National Transit Database (NTD) for calendar year 

2014 generally continues the downward trend in WMATA incidents.1 

Data for calendar year 2015, including the January 12, 2015 smoke incident near L’Enfant Plaza 

Station, is not included in this analysis. For purposes of this review, WMATA’s peers include the 

heavy rail transit systems operated by the Bay Area Rapid Transit (BART) district, the Chicago 

Transit Authority (CTA), the Massachusetts Bay Transportation Authority (MBTA), the 

Metropolitan Transportation Authority, New York City Transit (NYCT), and the Southeastern 

Pennsylvania Transportation Authority (SEPTA). 

In reviewing this safety performance data, in Tables 3 through 5 below, it is important to 

recognize that reports made to FTA’s SSO and NTD systems record information on only the 

most serious incidents to occur. This safety information includes the type of safety event 

(accident); the consequences, in terms of fatalities and injuries; and general causal information. 

This data is largely “lagging” because it captures what already happened, and does not reflect 

pre-cursor events, such a near-misses, employee safety reports, analysis of maintenance defects 

or formal observations of normal operations, that provide data-rich sources from which to 

examine and compare overall levels of safety among and between public transportation agencies 

and modes. 

Table 3. Rail Transit Safety Events, 2008 to 2013 

1 The data exclude suicide and trespassing-related events, as well as homicides. State safety oversight program 

submittals for calendar year 2014 are not yet available, however, for this assessment, FTA was able to incorporate 

preliminary fatality and injury data for calendar year 2014 from the National Transit Database (NTD). Preliminary 

NTD data excludes single-injury security events, homicides, and suicides. 

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•	 WMATA reported a significant decline in safety events since 2010. 

•	 In comparison, WMATA’s peer group has reported an overall increase in events during 

that same period. 

Table 4. Rail Transit Fatalities, 2008 to 2014 

•	 Only NYCT has reported more heavy rail safety-related fatalities since 2008 than 

WMATA. 

•	 WMATA accounts for 16% of heavy rail safety-related fatalities since 2008. 

•	 WMATA heavy rail safety-related fatalities have been on the decline since 2009, when 

the agency reported 12 fatalities. 

Table 5. Rail Transit Injuries, 2008 to 2014 

•	 WMATA has reported a general decline in safety-related injuries since a peak of 57 in 

2009. 

•	 Since 2008, WMATA reported the third most safety-related injuries amongst the 

identified peer group. 

•	 WMATA accounts for 15% of heavy rail safety-related injuries since 2008. 

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3.3 Metrobus 

WMATA’s Metrobus system was created in 1973, when WMATA consolidated service provided 

by four different private bus companies. Metrobus serves the District of Columbia, the suburban 

Maryland counties of Montgomery and Prince George’s and the Northern Virginia counties of 

Arlington and Fairfax and the cities of Alexandria, Fairfax and Falls Church. 

WMATA’s Metrobus system operates a fleet of approximately 1,500 buses over 328 routes on 

187 lines, servicing over 11,000 bus stops and 2,500 bus shelters, and carries roughly 465,000 

weekday passengers. The nation’s sixth largest bus fleet, WMATA’s Metrobus operates 24 hours 

per day, seven days per week. 

All Metrobuses are air-conditioned, equipped with two-way radios for emergency 

communication, video cameras, fire suppression systems, kneeling features and wheelchair 

capabilities. Metrobuses are 100% accessible for the elderly and disabled. The buses have silent 

alarms, emergency engine shutdown switches, and flashing lights located around the roof area 

that can be activated to alert police agencies for operator/passenger protection. 

To service its bus fleet, Metrobus manages ten full-service operating divisions, as shown below: 

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Currently the operating facilities located in the District of Columbia accommodate 45% of the 

total fleet, with those in Maryland and Virginia at 29% and 26% respectively. In addition, 

WMATA has two heavy repair shops, at the Carmen E. Turner facility and the Bladensburg 

Division, both located in Maryland. The Carmen E. Turner facility performs major corrective 

maintenance and the heavy repair shop at the Bladensburg Division serves as the home of the 

WMATA Heavy Maintenance Overhaul Program. Through this program, WMATA’s Board of 

Directors recently raised the expected service life of a standard Metrobus from 12 years to 15 

years and set the target average age of the Metrobus fleet at seven-and-a-half years. 

WMATA's buses are also 100% equipped with the DriveCam system, which is a comprehensive 

fleet safety and risk management program. This system assists with improving Metrobus safety 

by documenting incidents and assisting operators to develop safer, more efficient driving habits. 

As part of a five-year contract, the contractor will review and analyze video footage; and provide 

feedback on operator driving habits. The system detects when an operator makes a defensive 

move to avoid an accident, brakes or accelerates suddenly, turns sharply or is involved in an 

accident. The analysis is provided to management, supervisors, trainers and operators to 

encourage good driving habits, correct poor habits, and assist in investigations. 

The exact number of buses in WMATA's Metrobus fleet is determined by the projected annual 

bus schedule requirements with additional spares, to account for buses in maintenance and 

inspection or awaiting repair. The Metrobus fleet is comprised of the following power trains: 

Diesel, 15%; compressed natural gas (CNG), 30%; Hybrid, 45%; and Clean Diesel, 10%. The 

sub-fleets include buses manufactured by: New Flyer, Neoplan, Orion, NABI and Chevrolet, 

with model years ranging from 1997 to 2014. There are five buses in the special and historical 

fleet. As of early 2014, there were approximately 1,530 active buses with a peak service level of 

approximately 1,290 buses. 

3.4 Metrobus Safety Performance 

FTA also conducted an analysis of major safety events and resulting injury and fatality data for 

Metrobus, several peer transit agencies, and the full bus industry, based on the NTD Safety and 

Security module for calendar years 2008 to 2014. The data exclude single-injury security events, 

suicide and trespassing-related events, as well as homicides. Data from calendar year 2014 is 

preliminary. WMATA’s peers include bus systems operated by CTA, MBTA, NYCT, and 

SEPTA. 

This analysis shows that between 2008 and 2014, WMATA’s Metrobus service experienced a 

relatively steady trend in total safety events (averaging 188 per year), experienced fewer 

fatalities than its peer agencies during this period, and reported a modest downward trend in 

safety injuries after a peak in 2010 and 2011. As with Metrorail’s safety performance, Metrobus 

experienced positive safety gains in recent years when most of its peers and the industry as a 

whole experienced a declining safety performance. As with the data presented above on 

Metrorail’s safety performance, analysis focused exclusively on lagging indicators has 

limitations in terms of its predictive and comparative value. 

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Table 6. Bus Transit Safety Events, 2008 to 2014 

•	 WMATA accounts for about 4.6% of the non-rail safety events since 2008. 

•	 WMATA ranks third out of the five agencies in the peer group in terms of number of 

safety events reported since 2008. 

•	 WMATA has reported a modest downward trend in non-rail safety events since a peak in 

2010 and 2011. The industry, on the other hand, has reported a general increase in safety 

events over those years. 

Table 7. Bus Transit Fatalities, 2008 to 2014 

•	 WMATA accounts for about 1.3% of all non-rail safety fatalities. 

•	 WMATA ranks fifth out of the five peer agencies in terms of non-rail safety fatalities 

since 2008, averaging 1.14 fatalities per year. Only one other peer (MBTA) averaged less 

than two per year. 

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Table 8. Bus Transit Injuries, 2008 to 2014 

•	 WMATA accounts for about 4.4% of the non-rail safety injuries since 2008. 

•	 WMATA ranks third out of the five agencies in the peer group in terms of number of 

safety injuries reported since 2008. 

•	 WMATA reported a modest downward trend in non-rail safety injuries since a peak in 

2010 and 2011. The industry, on the other hand, has reported a general increase in 

injuries over those years. 

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4.0 FTA’s SMI Approach 

4.1 Methodology 

To conduct the SMI, FTA assembled 10 teams comprised of over 35 technical, safety and transit 

operations experts to conduct a comprehensive assessment. FTA’s SMI teams reviewed over 

1,000 documents submitted by WMATA departments and interviewed over 300 people at all 

levels of the Metrorail and Metrobus systems. FTA’s SMI team members conducted field 

observations of all shifts, and performed independent inspections, tests and measurements at 

WMATA’s rail and bus vehicle maintenance facilities and in the field at track, switch and signal, 

traction power, communications and ventilation system installations. 

FTA also conducted an independent safety culture assessment for front-line personnel, and 

reviewed the results against WMATA’s safety survey, which captured the opinions, attitudes, 

and safety experience of over 6,500 employees in 2014. Finally, to address Urgent Safety 

Recommendation R-15-7, FTA reviewed WMATA’s full audit of its tunnel fan and ventilation 

system, and conducted spot audits of preventive maintenance inspections at five fan shafts and 

two vent shafts, including observations regarding the process required for testing remote 

operation in both directions from the ROCC. 

Through all activities to assess WMATA’s safety performance, FTA’s SMI teams evaluated: 

•	 WMATA’s compliance with requirements specified in the agency’s track, traction power, 

signal, and rail and bus vehicle inspection, testing, and repair programs, and needed 

enhancements in these programs; 

•	 The performance and effectiveness of WMATA’s rail operations control center (ROCC) 

and bus operations control center (BOCC), and the overall quality of the radio system and 

visual display systems used to support and monitor rail and bus operations; 

•	 The effectiveness of WMATA’s roadway worker protection (RWP) program; 

•	 The quality and frequency of communication regarding maintenance and safety issues 

across WMATA departments and with WMATA’s executive leadership and board; 

•	 The quality of, and WMATA’s conformance with, initial and refresher training programs 

for major classifications of operations and maintenance employees; 

•	 Implementation of WMATA’s fatigue management program; 

•	 The quality and effectiveness of WMATA’s rules compliance and operational testing 

programs for major classifications of operations and maintenance employees, including 

supervisors and yard operations; 

•	 The quality and effectiveness of supervision provided for major classifications of 

operations and maintenance employees; 

•	 The quality and availability of data in WMATA’s information management systems to 

support enhanced safety risk assessment and hazard management activities; and 

•	 The quality and effectiveness of WMATA’s plans, procedures, and training programs for 

managing emergencies, and ensuring the readiness of WMATA’s front-line personnel 

and emergency responders. 

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4.2 Findings and Required Actions 

Based on this evaluation, FTA finds that, over the last five (5) years, WMATA has implemented 

new management initiatives and programs to address safety concerns and improve safety culture. 

WMATA has made advances in many areas, including: 

•	 Standing up a significantly strengthened Safety Department, reporting directly to the 

General Manager/Chief Executive Officer, with 67 total positions, including a range of 

expertise, backgrounds, and professional engineering and safety certifications, 

supplemented by a technical services contract for engineering and auditing support; 

•	 Re-building WMATA’s safety committee structure, and establishing clear procedures and 

processes for the management of Local Safety Committees, Departmental Safety 

Committees and the Executive Safety Committee; 

•	 Initiating a first-of-its-kind, scientifically based fatigue management program for public 

transit employees; 

•	 Initiating and sustaining a biennial employee safety culture survey assessment and 

sharing the results back with supervisors and employees; 

•	 Establishing new hiring and training plans to “right size” the agency to address staffing 

needs for the new Silver Line extension and service expansions; 

•	 Establishing an enhanced Roadway Worker Protection program that incorporates lessons 

learned and effective practices from other transit agencies and the Federal Railroad 

Administration; 

•	 Developing new internal auditing and quality programs to assess (more accurately) the 

agency’s level of conformance with plans, procedures and requirements; 

•	 Developing new training programs to enhance skills for technical employees; 

•	 Developing and carrying out two long-term capital investment programs (MetroForward 

and Momentum) to bring rail vehicles and infrastructure and buses and facilities into a 

better state of repair; 

•	 Working cooperatively with the TOC to close 201 corrective action plans, stemming 

from audits, accidents, and internal reviews, since 2012; and 

•	 Completing work to close out 26 safety recommendations issued by the NTSB since 

2005, including completion of major programs to restore the reliability of the ATC 

system, to replace 178 No. 8 standard turnouts with guarded turnouts on mainline track, 

and to develop an industry-leading program for confidential close call reporting with 

WMATA’s Amalgamated Transit Union (ATU) Local 689. 

While FTA acknowledges WMATA’s clear and substantial progress over the last five years, 

FTA’s SMI also identified organizational deficiencies and operational concerns that continue to 

limit the agency’s effectiveness in recognizing and resolving safety issues and hazards. FTA’s 

SMI found that, in key areas, WMATA’s organization is not effectively balancing safety-critical 

operations and maintenance activities with the demand for passenger service. 

Specifically for Metrorail, FTA’s SMI team determined that WMATA work crews do not have 

sufficient access to the rail ROW to perform critical inspection, testing and maintenance 

activities. FTAs’ SMI team also found that for some of Metrorail’s more complicated technical 

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systems, shared responsibilities for maintenance inspections and repairs, training, and 

operational testing, are not always well managed, leaving one department’s top safety priorities 

unaddressed by another department with different focus areas and considerations. In addition, 

FTA’s SMI team identified clear deficiencies in the availability, quality and performance of 

technical training, refresher training, and rules compliance and operational testing activities. 

Poorly functioning and poorly utilized information management systems and technology also 

limit the effectiveness of WMATA’s training, rules checks and operational testing, and 

maintenance programs and activities. 

Perhaps most significantly, FTA’s SMI team found serious safety lapses in the ROCC, related to 

the training and certification of rail traffic controllers; the ROCC structure, organization and 

staffing; the availability of checklists, procedures, manuals and tools; the quality of the radio 

system and radio communications; and the performance of the AIM system to visually display 

and monitor the status of the rail transit system. Collectively, these issues significantly impact 

the ability of the Metrorail system to schedule and conduct maintenance work, to manage 

abnormal and emergency events, and to ensure the safety of trains and personnel on the ROW. 

For the Metrobus system, FTA’s SMI team found many effective practices relating to 

WMATA’s industry-leading fatigue management program and WMATA’s use of cameras and 

DriveCam technology on bus vehicles to monitor the safety of service. FTA’s SMI team also 

generally observed a streamlined and effective process for the selection of bus operators, a 

comprehensive new-hire bus operator training program, as well as an extensive training program 

for new bus mechanics. FTA’s SMI team determined that WMATA conducts a general 

knowledge assessment survey for mechanics, and supports a Mechanic Apprentice Program to 

guide mechanics through increasing levels of qualification and certification. Metrobus requires 

Automotive Service Excellence (ASE) certification of all mechanics, and provides a cash 

incentive program for mechanic performance. Metrobus also works to incorporate information 

technology, and to thoroughly document maintenance activities in its maintenance management 

work order system. 

While FTA’s SMI team found many effective practices at Metrobus, FTA’s SMI team also 

identified concerns in WMATA’s Bus Operations Control Center (BOCC) regarding the lack of 

manuals, documented checklists and procedures for bus dispatchers, and a general level of 

informality in bus radio use and communications. FTA’s SMI team also determined that 

WMATA’s bus operating and maintenance departments have unmet training needs, and do not 

generally conform with all requirements specified in rules compliance and operations testing 

programs, including annual refresher requirements. 

FTA’s SMI team identified areas where automated systems could greatly improve safety 

processes, and where specific types of maintenance inspections and reviews would benefit fleet 

safety performance. FTA also found that Metrobus employees at all levels of the organization 

identified their most significant safety concern as WMATA’s ability to protect bus operations 

personnel from violent, disgruntled, or disruptive passengers and members of the public. 

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4.3 Findings, Required Actions and Close-out Process 

As a result of this SMI, FTA issues 44 safety findings in eight categories regarding WMATA’s 

Metrorail system and 10 safety findings in five categories regarding WMATA’s Metrobus 

system. To address these findings, FTA is issuing Safety Directive 15-1, which uses FTA’s new 

MAP-21 authority to direct WMATA to take specific actions to create and comply with an FTAapproved action plan that addresses gaps in operations and maintenance potentially affecting 

public safety. 

In Safety Directive 15-1, FTA identifies 78 distinct actions to be completed by WMATA’s 

Metrorail system and 13 distinct actions to be completed by WMATA’s Metrobus system to 

enhance public safety. Appendix C provides a tracking matrix with the findings and required 

actions issued in FTA’s Safety Directive 15-1. 

WMATA will have 30 days to respond to Safety Directive 15-1, to provide additional 

information for consideration, and to propose any equivalent alternate actions for consideration 

by FTA’s Acting Administrator. Sixty days thereafter, WMATA must submit a tracking matrix 

to FTA that identifies the specific actions that will be performed to address each required 

element specified in this Safety Directive; the milestone schedule for completing corrective 

action; the responsible parties for action and their contact information; and the verification 

strategy for ensuring the completion of required work. In preparing this response, WMATA will 

have the opportunity to propose its prioritization of action and available resources to address 

FTA’s required actions. 

WMATA Metrorail System 

Categories of Metrorail System Finding Number of Findings and Required Actions 

• Category R-1: Inadequate Rail Operations Control 

Center Staffing and Procedures 

14 Findings and 21 Required Actions 

• Category R-2:Ineffective Training, Operational Testing 

and Rules Compliance Programs 

8 Findings and 22 Required Actions 

• Category R-3: Insufficient Track Time for Maintenance 4 Findings and 4 Required Actions 

• Category R-4: System-wide Maintenance Issues 7 Findings and 7 Required Actions 

• Category R-5: Fire/Life Safety and Emergency 

Preparedness 

2 Findings and 7 Required Actions 

• Category R-6: Condition and Performance of Tunnel 

Ventilation System 

3 Findings and 4 Required Actions 

• Category R-7: Performance of Information 

Management Technology 

4 Findings and 8 Required Actions 

• Category R-8: Outstanding Items from Previous FTA 

Audits and Reviews 

2 Findings and 5 Required Actions 

Total 44 Findings and 78 Required Actions 

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WMATA Metrobus System 

Categories of Metrobus System Finding Number of Findings and Required Actions 

• Category B-1: Concern over Protection of Metrobus 

Operations Personnel 

1 Finding and 2 Required Actions 

• Category B-2: Limited Availability of Training for 

Operations and Maintenance Personnel 

2 Findings and 2 Required Actions 

• Category B-3: Inconsistent Operational Testing and 

Rules Compliance Checks 

3 Findings and 4 Required Actions 

• Category B-4: System-wide Maintenance Issues 2 Findings and 2 Required Actions 

• Category B-5: Lack of Information Management 

System Technology 

2 Findings and 3 Required Actions 

Total 10 Findings and 13 Required Actions 

FTA will review and approve WMATA’s work plans, and will monitor the agency’s progress in 

resolving each finding and required action. FTA will conduct monthly meetings with WMATA 

to review progress until such time as FTA determines that these meetings are no longer needed 

or may be conducted with less frequency. FTA will also coordinate with the TOC regarding the 

review and final approvals of corrective action plans for the Metrorail system. 

FTA is also asking WMATA’s Board of Directors to closely monitor the time and resources 

made available to WMATA’s operations and maintenance departments to conduct critical 

inspection, testing, training, and repair activities. Appendix D provides a copy of WMATA’s 

organization chart in effect at the time of the SMI. 

WMATA participated fully in the SMI and FTA anticipates that cooperation to continue through 

the completion of all corrective actions in response to this report. 

In addition, in support of the SMI, FTA performed a Safety Management System (SMS) Gap 

Analysis to evaluate WMATA’s approach to safety management practices as they relate to a 

fully mature SMS. The SMS Gap Analysis was not an exercise in safety compliance. SMS is a 

management approach adopted by FTA that ensures each public transportation agency has the 

necessary organizational structures, accountabilities, policies, and procedures in place to direct 

and control resources for safety management. SMS is not a requirement in the public 

transportation industry. Thus, this cooperative effort with WMATA serves as a tool for 

continuous improvement in WMATA SMS development and implementation activities. 

SMS has four levels of maturity: Initiating, Planning, Implementing, and Managing and 

Monitoring. The SMS Gap Analysis identified an overall WMATA SMS maturity level between 

Planning and Implementing with some areas at the Managing and Monitoring level. SMS is new 

to the public transportation industry and may take a transit agency two to four years to reach the 

full maturity level depending on its size and complexity. To further advance its SMS efforts, 

WMATA has accepted an FTA invitation to participate in a SMS pilot program. 

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5.0	 Metrorail Findings and Required Action 

FTA organizes its discussion regarding the findings and required actions from its SMI at 

WMATA Metrorail into eight over-arching categories of safety critical concerns: 

•	 Category R-1: Inadequate Rail Operations Control Center Staffing and Procedures 

•	 Category R-2: Ineffective Training, Operational Testing, and Rules Compliance 

Programs
 

•	 Category R-3: Insufficient Track Time for Maintenance 

•	 Category R-4: System-wide Maintenance Issues 

•	 Category R-5: Fire/Life Safety and Emergency Preparedness 

•	 Category R-6: Condition and Performance of Tunnel Ventilation System 

•	 Category R-7: Performance of Information Management Technology 

•	 Category R-8: Outstanding Items from Previous FTA Audits and Reviews 

Within these categories, FTA makes specific findings based on the results of interviews, 

document and records reviews, field observations, and independent inspections, testing and 

measurements. In Safety Directive 15-1, FTA issues required actions that WMATA must take to 

address the findings described in each category of this SMI report. Safety Directory 15-1 also 

establishes required response times, a process for FTA approval of work plans, and the FTA’s 

approach to the monitoring of the implementation WMATA’s work plans. 

5.1	 Category R-1: Inadequate Rail Operations Control Center Staffing 

and Procedures 

FTA’s SMI team found that the staffing, organization, and tools used to manage the ROCC could 

be significantly improved to enhance effectiveness and reduce opportunities for distraction and 

miscommunication. FTA’s SMI team identified 14 findings regarding ROCC staffing, ROCC 

procedures and training programs, the quality of WMATA’s radio communications and radio 

discipline, and the performance technology systems. 

Situation

WMATA’s Office of Rail Transportation (RTRA) is responsible for managing the ROCC. 

WMATA’s ROCC is staffed 24 hours per day, seven days per week, and serves as a command 

and control facility from which all aspects of the Metrorail system are directed and from which 

decisions are made regarding normal, abnormal and emergency operations. The ROCC also 

serves as the primary point of coordination for all operational decisions affecting rail service. 

This coordination usually includes both internal WMATA departments as well as external 

emergency response agencies. 

The ROCC provides positive control over all train movements, station activities, and subsystems 

(power, ATC, automatic fare collection, and communications) following operating rules and 

SOPs set forth in WMATA’s MSRPH, supporting Operations Administrative Procedures 

(OAPs), and temporary and permanent orders. 

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The ROCC monitors and controls train movements through three consoles, designated as: 

•	 Operations 1 (Ops 1) - Red Line; 

•	 Operations 2 (Ops 2) - Blue/Orange/Silver Lines; and 

•	 Operations 3 (Ops 3) - Blue/Yellow/Green Lines (Blue Line south of Rosslyn). 

Two rail traffic controllers or RTCs staff each console—a radio controller and a train “buttons” 

controller. The console is designed so that the radio- and train- RTC positions can be worked 

from either side of the console. One RTC can also work the console in the absence of the other. 

The radio controller communicates with train operators by radio and is responsible for ensuring 

conformance with policies and procedures and for keeping train operators and personnel 

informed of all unusual occurrences on the rail transit system. The radio controller also 

communicates with supervisors and maintenance personnel in the field. The buttons controller is 

responsible for such tasks as setting route alignments and signals, setting train performance 

levels, and coordinating the addition or replacement of trains when necessary. 

The ROCC, employing a central computer system called the Advanced Information Management 

or AIM system, implements train control strategies as necessary to regulate traffic flow. These 

control strategies may be preprogrammed strategies that are carried out automatically by the 

central control mainframe computer, or they may be strategies implemented manually by ROCC 

line controllers. The AIM system provides a visual display and alarm status monitoring for train 

positions, switch positions, signal status and malfunctions, and status of support systems such as 

ventilation, drainage, fire and intrusion alarms, traction power system status, and drainage 

pumping station alarms. RTCs must respond to alarms and notifications from the AIM system to 

manage service and ensure the proper functioning of equipment and systems. 

Between stations, the RTCs can manually control train movements by changing signal aspects or 

switch alignments at interlockings at certain control points or through direct communication with 

train operators via a two-way radio system. RTCs also use indicators available in the AIM 

system to program reminders in the visual display system regarding the presence of workers on 

the rail transit ROW, and to highlight unusual situations, manual blocks, or issues with signals. 

The MOC, also part of the ROCC, is responsible for coordinating and monitoring all personnel 

and equipment responding to emergencies, revenue train delays, unusual occurrences, 

equipment, and facility malfunctions having the potential to disrupt or affect revenue service on 

the rail and bus systems. The MOC directs the performance of preventive maintenance activities 

in accordance with OAP 200-3 and with applicable manufacturers’ recommended maintenance 

practices. The MOC also uses the following OAPs: 200-5, 200-9, 200-27, 202-5, 204-1, 208-1, 

210-3, 210-4, 210-6, and CMNT SOPs 1.04, 1.05 and 1.06, to direct corrective and supportive 

maintenance activities. 

•	 Finding R-1: WMATA’s Rail Operations Control Center is significantly 

understaffed. 

Depending on the day of the week and the level of service required, WMATA’s ROCC typically 

controls the movement of between 124 and 144 passenger trains per day on the Metrorail system. 

In addition, the ROCC controls access to the ROW for inspections, emergency repairs, scheduled 

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maintenance activities, and during the OWL nighttime shift, for a large volume of work activity, 

stemming from corrective maintenance requirements and over 200 capital projects, the majority 

of which are focused on rehabilitating, upgrading or maintaining critical rail transit 

infrastructure. Given the size of the Metrorail system and volume of passenger service and 

maintenance activities, WMATA’s ROCC is one of the busiest control centers in the transit 

industry. 

In 2012 and 2013, WMATA’s executive leadership team conducted a workload assessment for 

the ROCC, including a comprehensive review of ROCC requirements and activities, including 

plans for the new Silver Line and eight-car train implementation. As a result, for 2014, WMATA 

increased staffing by budgeting for the following positions to the ROCC: 

• Director (1) 

• Superintendents (2) 

• Assistant Superintendents (7) 

• Rail Traffic Controllers (52) 

• Rail Service Liaisons (4) 

• Rail Operations Information Center Superintendent (1) 

• Rail Operations Information Specialists (19) 

• MOC Superintendent (1) 

• MOC Assistant Superintendents (6) 

• MOC personnel (20 Supervisors plus 5 Service Dispatchers) 

At the time of FTA’s SMI, while most ROCC positions were staffed at or close to their budgeted 

levels, WMATA’s ROCC had 34 Rail Traffic Controllers on staff, almost 20 positions below 

authorized levels. These 34 RTCs fill what is arguably the most challenging job at WMATA, 

providing 24 hour, seven-day-a-week coverage for both radio and button functions across the 

three desks that control all six Metrorail lines and the midnight OWL maintenance period. 

Because of the difficulty of the controller function, and the limited number of RTCs, the safety 

and efficiency of the entire Metrorail operation depends on the experience, skills and decisionmaking capabilities of this very small number of employees. Due to collective bargaining 

limitations of 12 hours worked within a 24-hour period (8-hour shift plus 4-hours of overtime), 

WMATA’s ROCC has not been a central focus of the agency’s Fatigue Management Risk 

Program because RTCs are afforded the opportunity for 8-hours of uninterrupted sleep between 

shifts. 

However, FTA’s SMI team found that, in spite of WMATA’s efforts to enhance staffing, the 

ROCC remains, in the words of one Assistant Superintendent, “an over-time driven room.” Due 

to the around-the-clock nature of ROCC operations, individual RTCs may work six or even 

seven 12-hour days per week. 

In interviews, ROCC personnel reported that overtime pay compensates for what they consider 

to be the lower salaries offered to WMATA’s RTCs when compared to controllers or dispatchers 

in other industries or public safety agencies. 

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Even with overtime available for RTCs, however, ROCC management struggles with ensuring 

coverage for all shifts, and Superintendents and Assistant Superintendents also work long hours 

to support the functioning of the ROCC. 

• Finding R-2: RTC re-certification has not occurred as required. 

Given the dynamic nature of operating rail transit systems, where methods and procedures 

change frequently, personnel assigned to the control center environment must receive periodic 

retraining or recertification. WMATA, following industry safety standards, set an annual 

requirement for RTC re-certification. 

The purpose and intent of re-certification is to ensure that RTC personnel are current with regard 

to newly developed standards, procedures and rules as they apply to the operating system. For 

example, since WMATA last updated its rulebook in 2014, the agency has issued over 40 

temporary and permanent orders, initiated major construction on Phase 2 for the Silver Line, 

placed the 7000-series vehicle in service, and returned to ATO on the Red Line during peak 

service hours. Several new projects have been undertaken to upgrade infrastructure, and 

operations and maintenance personnel face a dynamic range of issues in the field, which must be 

managed and coordinated with the ROCC. 

Further, as requirements and standards are implemented or modified for the ROCC, it is essential 

to determine the extent to which assigned personnel are conversant with such changes. The recertification process typically includes presentation material and written exams. In some 

instances, observations of RTC performance may also be included. When re-certification is 

achieved, the employee’s personnel record or training file is updated accordingly. 

Records requested and reviewed by FTA’s SMI team confirmed that RTCs had not been recertified since 2012, though WMATA’s internal procedures and System Safety Program Plan 

require annual re-certification. Given the changes to WMATA’s operating environment since 

2012, FTA finds this failure to re-certify RTCs as a significant breach in WMATA’s program to 

ensure their on-going proficiency in WMATA’s operating requirements, rules and changing 

infrastructure and equipment. 

• Finding R-3: RTCs receive limited refresher training and no road days. 

FTA’s SMI team documented high levels of overtime in WMATA’s ROCC, and, due to low 

RTC staffing levels, an unwillingness or inability to remove RTCs from duty for training or road 

days. Outside of scenarios and scripts reviewed with RTCs by the ROCC Assistant 

Superintendents, FTA’s SMI team was only able to verify an extremely limited amount of 

refresher training provided to RTCs since 2012, typically targeted to a particular program, such 

as Roadway Worker Protection. Further, FTA’s SMI team found that RTCs, because of their 

value to the operation of the rail transit system, rarely leave the ROCC. 

FTA’s SMI team confirmed that no “road days” or “field familiarization” days were scheduled or 

readily available for RTCs – most veteran RTCs interviewed had not seen the field or roadway in 

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over six years. For the Silver Line, RTCs were provided a DVD of the alignment, rather than an 

actual tour. Veteran RTCs cited this lack of recent field experience as a major challenge in the 

performance of their work for a dynamic and changing system. 

•	 Finding R-4: There is a high level of noise and distraction in the ROCC, and a lack 

of electronic controls in the AIM system to prevent errors. 

In addition to the three RTC desks, the ROCC contains desks used by the Maintenance 

Operations Center for Power, ATC and Communications, Plant, and Elevators and Escalators, as 

well a Car Maintenance desk, Office of Emergency Management (OEM) desk, the Rail 

Operations Information Center (ROIC) and the Public Address Announcer along with the Social 

Media desks. All of these desks monitor radio transmissions using speakers listened to by their 

controllers, specialists and personnel. With no headsets or earphones used by ROCC personnel, 

multiple speakers broadcasting radio channels throughout the room contributes to noise and 

distraction in the ROCC, and background interference on radio communications. 

FTA’s SMI team also observed Assistant Superintendents or Superintendents requesting 

information from an individual RTC by “yelling down” to their location. This practice also 

contributes to the overall noise and disruptive atmosphere in the ROCC. When interviewed, 

several RTCs stated that the ROCC was a “noisy” office, and that the desk speakers contributed 

to the ambient noise when transmitting over the radio to the field. 

To assess the safety performance of ROCC since 2012, FTA’s SMI team met with WMATA’s 

Safety and Environmental Department and the TOC to review completed accident investigation 

reports, including ROCC incident reports and supervisor reports, along with corrective action 

plans and status, for the following recent incidents where RTC errors or miscommunication 

between an RTC and a train operator resulted in trains being directed into work zones, through 

red signals, or where power was unintentionally restored in a work zone: 

•	 March 6, 2012 – D& G Junction – RTC routed a train into an active work zone. 

•	 April 24, 2012 – Rosslyn – The first car of a six-car consist derailed at a switch just after 

ROCC instructed the operator to pass a red signal and traverse the switch (which was not 

clamped). 

•	 October 31, 2012 – East Falls Church – RTC sent a Prime Mover into work area after 

authorizing the work crew to enter the ROW. 

•	 November 7, 2012 – Landover – RTC restored power to an area with roadway workers 

present. 

•	 January 30, 2013 – Anacostia – self-evacuation of stranded passengers from a train 

resulting from miscommunication. 

•	 May 13, 2013 – red signal violation by Train 713 related to miscommunication. 

•	 May 28, 2013 – red signal violation by Train 923 related to miscommunication. 

•	 August 7, 2013 – third rail power energized in a work area. 

•	 August 15, 2013 – rail buggy derailed when ROCC failed to confirm that it had cleared 

an interlocking and threw a switch. 

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•	 October 14, 2013 – collision in West Falls Church Service & Inspection Shop when train 

operator was not informed that a pair of cars of the train in motion had its brakes cut out, 

and the operator thus was unable to stop the train in time. 

•	 January 11, 2014 – RTC instructed a train operator to offload a train that was not fully 

berthed at the platform. 

•	 September 17, 2014 – ROCC permitted a prime mover to enter a work zone. 

•	 December 29, 2014 – Near miss involving workers in the ROW at King Street Station. 

Through this process, FTA’s SMI team confirmed a high level of activity and distraction for 

RTCs. Also, in several instances, the lack of a formal checklist regarding the steps to be taken to 

manage or troubleshoot a particular situation, combined with the lack of a clear radio repeat-back 

from the field, resulted in both the ROCC and the train operator making mistakes that impacted 

the safety of train operations. FTA’s SMI team also confirmed that WMATA does not require 

train operators who request permission to either enter a main track, or turn a train for a return 

trip, to acknowledge receipt of the updated radio announcements from the ROCC regarding the 

location of wayside workers. 

FTA’s SMI team also confirmed that the AIM system, used to visually display and monitor 

system performance, generates a high volume of alarm indications that must be managed by 

RTCs at their desks. In the aftermath of the June 22, 2009 Fort Totten accident, the NTSB 

focused on the large volume of alarms related to the signal and train control system (thousands 

per day, most of which were generated and then dismissed automatically by the AIM system if 

RTCs did not take action). While there have been improvements in this situation, the AIM 

system still generates a high level of “noise” to be filtered out by individual RTCs, including 

hundreds of notifications per day. WMATA has re-committed to reviewing protocols for alarms 

in the ROCC to identify critical versus non-critical notifications, and to reduce RTC 

responsibilities for non-critical notifications. 

As a result of this review, FTA also identified the lack of electronic blocks or prohibits available 

for RTCs to prevent specific train movements and to manage unusual situations. Due to the way 

the AIM system interfaces with the wayside train control system, there are limitations regarding 

the ability of RTCs to enforce temporary speed restrictions or absolute blocks electronically with 

prohibits that would stop or slow a train on the ROW. 

Several RTCs interviewed by FTA’s team indicated that absolute blocks were time-consuming to 

implement electronically on the AIM system, and not always practical or encouraged during 

busy periods. For the WMATA system, speed restrictions are enforced wayside with speed 

couplers, however, in cases of temporary speed restrictions, verbal commands from RTCs issued 

over the radio are relied upon to reduce speeds until wayside controls can be implemented. In the 

reviewed accident reports, FTA’s SMI team observed inconsistencies in the level of 

acknowledgement and repeat-back regarding safety critical verbal commands from RTCs to train 

operators. Many of WMATA’s peer transit agencies have the capability to enforce speed 

restrictions electronically from the ROCC. 

The ROCC also uses advisory “blue man” blocking devices to protect the Roadway Worker in 

Charge (RWIC) or personnel along the roadway; however, these blocking devices are just visual 

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reminders that appear on the AIM display regarding the presence of workers. RTCs can still 

route trains or clear signals into that affected track or block segment. 

FTA’s SMI team finds that ready availability of additional electronic controls would have 

prevented several of the accidents reviewed by FTA, WMATA and TOC, and would have helped 

RTCs better manage the level of noise and distraction in the ROCC. 

•	 Finding R-5: WMATA RTCs are required to perform many tasks outside of 

industry standards. 

WMATA’s RTCs are required to perform many tasks outside of industry standard practices (i.e., 

WMATA does not have a Power Director position, or specific desk for managing RWP issues or 

access, and RTCs are also responsible for documentation regarding trouble reports and other 

issues on the mainline that is then picked up by the appropriate MOC or CMNT desk person). 

With these added responsibilities, RTCs often create bottlenecks that exacerbate track access 

issues for work crews and can slow response to certain situations. 

For example, due to the volume of calls and activities, individual RTCs working specific line 

desks may be unable to follow-up with maintenance personnel who have called in from the field, 

leaving them waiting, sometimes for hours, for permission, authorization, or verification that a 

command or activity controlled from the ROCC is functioning as intended. This situation can be 

a deterrent to the inspection and testing of safety-critical systems related to communications, 

fire/life safety, accessibility, and intrusion detection. 

FTA’s SMI identified many opportunities to remove work from RTC desks to reduce distraction, 

bottlenecks and inefficiencies during regularly scheduled passenger service, off-peak service, 

and the OWL shift. FTA’s SMI team also discussed with WMATA the possibility of separating 

the six Metrorail lines into six or more separate desks to more evenly distribute the workload. 

Currently, while the Blue/Orange/Sliver Line desk, nicknamed “The Monster”, handles a 

disproportionate volume of calls and activities, all three desks experience a high level of activity 

compared to peer transit agencies. 

•	 Finding R-6: Radio discipline is poor. 

FTA’s SMI team confirmed in interviews and observations at the ROCC that radio discipline is 

not actively enforced to reduce radio congestion and miscommunication. FTA’s SMI team noted 

that RTCs often did not listen long enough to make sure the channel was not being used before 

beginning transmission. Required identifications were not consistency provided from train 

operators or field units and personnel. Word-for-word repeat-backs were rarely observed 

between RTCs and train operators or field personnel, and transmissions were not always 

formally ended or acknowledged. 

FTA’s SMI team also observed confusion in communication resulting from lack of proper 

protocol for language and terminology used over the radio – to include 100 percent word-forword read-back for safety-related instructions and unusual train movements. Interviews and 

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observations in rail yards and on trains confirmed the difficulty of understanding radio 

communications in certain situations. 

In light of its review of recent accidents where miscommunication played a major role, FTA’s 

SMI team believes that WMATA must do more to ensure field personnel and train operators 

understand directions and communications. For example, the Port Authority Trans-Hudson 

(PATH) established a program to require and manage word-for-word read-backs for mandatory 

directives issued for all unusual situations related to starting up service in the restored World 

Trade Center station under manual block operations, including: manual block operations 

(bypassing red or inoperative signals), single tracking without signal indication, roadway 

workers entering the ROW, and unusual train movements or safety situations (energizing and deenergizing the third rail). FTA’s SMI team discussed with WMATA personnel how a similar 

approach could improve the quality of radio communication on the Metrorail system. 

• Finding R-7: WMATA’s ROCC lacks formal procedures, manuals and checklists. 

WMATA’s RTCs are largely veterans, who have worked many different jobs at WMATA prior 

to becoming controllers, such as bus operator, train operator, field supervisor, and interlocking 

operator. FTA’s SMI team found that these veterans have established a strong culture regarding 

how things should be done in the ROCC. This approach reflects the variety of Metrorail’s 

operations, the fluidity of daily activities and events, and the fact that most veteran RTCs prefer 

to run the Metrorail system largely based on their past experience and the information “in their 

heads” as opposed to the consistent and dedicated use of checklists, transfer records, and AIM 

system electronic tracking tools. 

As part of the investigation into WMATA’s management of the smoke incident at L’Enfant 

Plaza station, on February 11, 2015, the NTSB issued Urgent Safety Recommendation R-15-9 to 

WMATA related to the lack of detailed written tunnel ventilation procedures for ROCC staff: 

“Develop and implement detailed written tunnel ventilation procedures for operations 

control center staff that take into account the probable source location of smoke and fire, 

the location of the train, the best evacuation route, and unique infrastructure features; 

these procedures should be based on the most effective strategy for fan direction and 

activation to limit passengers’ exposure to smoke.” 

In interviews and observations, FTA’s SMI team learned that many veteran RTCs questioned the 

effectiveness of the traditional checklist-based dispatching tools used in other industries and 

recommended by the NTSB. FTA’s SMI team also found that while WMATA issued memos and 

other documentation to ROCC personnel regarding roles, responsibilities and requirements, and 

while specific contact information and other work sheets were available, a formally compiled, 

reviewed and updated “ROCC Manual” with all office procedures and interpretations of rules or 

instructions pertaining to the RTC’s duties and use of the AIM system was not available. FTA’s 

SMI team also did not find any checklist tools or system or station schematics available for 

RTCs to dispatch service or manage incidents. 

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This situation creates significant challenges for WMATA. As senior RTCs are retiring, they take 

with them the critical information they use to manage the system. Also, the lack of written tools, 

checklists and procedures makes it more difficult to train new RTCs and to conduct formal 

evaluations regarding the performance of veteran and new RTCs alike. 

Finally, the lack of written checklists and commitment to their use means that WMATA as an 

agency does not fully direct the daily administration of the information used by RTCs to guide 

the system. Interviews with technicians in Car Maintenance, for example, indicated that vehicle 

trouble-shooting information provided to train operators by RTCs was often incorrect, and that 

consistent use of a trouble-shooting checklist would greatly enhance performance of this critical 

function. Interviews with other departments, including the Power branch and ATC technicians, 

highlighted issues with misused terminology, incorrect or vague language, and poor directions 

for activities that would be improved with the dedicated use of checklists by RTCs. Other 

industries, from aviation to the medical profession, have demonstrated the importance of 

checklist tools in preventing avoidable failures, better managing emergencies, and ensuring the 

consistent management of daily activities. 

•	 Finding R-8: Personal cell phones are used by RTCs in the ROCC. 

FTA’s SMI team members observed WMATA’s RTCs carrying and using their personal cell 

phones while on-duty. FTA’s SMI team also found that WMATA’s cell phone policy for the 

ROCC, which allows ROCC personnel to carry and use their cell phones if they step away from 

their desks is vague, easy to violate, and contributes to distraction in the ROCC. WMATA has a 

strong electronic device policy imposed on all other safety-sensitive personnel but has elected to 

exclude the ROCC. 

•	 Finding R-9: No formal transfer records are used when RTCs complete shift 

briefings. 

While WMATA plans to allocate RTCs with 30 minutes of overlapping shift time to coordinate 

the transfer of information from the previous shift; the current practice is less formal. For 

example, FTA’s SMI team observed the transfer between two “Button Operators”, which 

consisted of the verbal communication “True Blue” – a term used to indicate that several 

workers are on the roadway with “TAW” (Train Approach Warning) protection, and nothing else 

stated. The transfer between the two “Radio Operators” was written into a log book with no 

information listed other than a few track circuit locations that were problematic. The outgoing 

RTC also did not log off on the AIM system, allowing the incoming RTC to utilize the AIMS 

system under another name. No signature was written anywhere in the logbook. At other times, 

FTA’s SMI team observed shift briefings occurring informally between RTCs as coats were 

being put on and bags being gathered up to leave, with nothing formally written down or signed. 

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•	 Finding R-10: WMATA does not use industry standard rules reviews and scenario 

testing activities. 

FTA’s SMI team did not witness RTCs working with each other or management to review and 

reinforce critical ROCC procedures at any point during its observations in the ROCC, nor did 

FTA find that WMATA conducts routine “tabletop exercises” for RTCs. Most of the discussion 

and interaction between supervisory personnel and RTCs observed by FTA’s team focused on 

RTC activities related to trouble-shooting trains and single-tracking, the most commonly 

performed activities at the ROCC to manage disabled trains and ATC or track failures requiring 

emergency repairs. Interviews confirmed that, while major incidents were reviewed with the 

RTCs and supervisory staff, there was very limited simulation or practice for other events, such 

as broken rails, third rail power shut downs, passengers who jump or fall onto the rails, sick 

customers, derailments, station and tunnel fires, and other types of service disruptions or 

emergencies. 

FTA’s SMI team also did not find that RTCs went through monthly tabletop drills/scenarios or 

weekly SOP reviews. These are industry standard practices designed to enhance the proficiency 

of RTCs and ensure their overall awareness regarding operating rules, temporary and permanent 

orders, and how they should be interpreted and carried out in the field under chancing operating 

conditions. FTA also confirmed that WMATA does not have a formal program of efficiency 

testing for RTCs to ensure their conformance with rules and SOPs. 

•	 Finding R-11: WMATA faces major challenges in recruiting and training new 

RTCs. 

Over the last few years, WMATA has been attempting to bring in controllers and dispatchers 

with military, aviation, and transportation experience. However, WMATA has been unable to 

successfully recruit, train, qualify and retain new RTCs. A major hiring and training effort over 

the last 5 years has only increased the total number of RTCs in the ROCC by 3 positions since 

2011 – from 31 RTCs to 34 RTCs. 

At the time of the SMI, in the most recent class of 12 new trainees from external agencies, only 

four RTC trainees made it through the program to obtain certification, and only two of the four 

RTC trainees were actually working in the ROCC. This situation reflects a very poor return in 

training investment, and a major challenge for WMATA moving forward. 

•	 Finding R-12: WMATA’s training program for new RTCs is inadequate. 

FTA’s SMI team identified major gaps in training for new RTCs: 

•	 A Third Party Vendor developed the key modules for new RTCs regarding the operation 

of the AIM system and the performance of their duties; 

•	 This vendor had not worked previously as an RTC and did not have a background in 

ROCC operations; 

•	 High-level sign-offs and approvals were provided for the training by WMATA personnel, 

however, in-depth reviews and workshops were not conducted to fully vet the materials; 

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•	 No performance standards have been developed for being a WMATA RTC, and 

therefore, could not be used to guide the training or the evaluation of new RTC 

performance; 

•	 An incomplete approach to testing or certification was developed by the vendor, and RTC 

trainees were used to develop or complete test questions; and 

•	 No mentor program was established for new RTCs as part of the training. 

FTA’s SMI team identified inconsistencies, errors, and missing and unfinished sections in the 

training materials and PowerPoint presentations used to train new RTCs on the AIM system and 

their roles and responsibilities. The lack of formal printed and electronic tools to support the 

dispatching of service further exacerbates the impacts of the weak training program. 

WMATA has used vendors, RTCs and Assistant Superintendents to deliver training, but due to 

the poor quality of materials and the number of gaps in training, new RTCs face enormous 

challenges in mastering the material. Due to significant resource limitations, WMATA has no 

dedicated trainer for new RTCs to work with them through the entire process. WMATA also 

only has four AIM system simulators to train new RTCs, but classes may have up to 12 trainees, 

so trainees are not able to complete all exercises and miss valuable lessons. 

The poor quality of initial classroom training increases reliance on on-the-job training. However, 

since veteran RTCs manage events in the way they believe is effective, their preferences for 

handling incidents may or may not correspond to what new RTC trainees have been taught in the 

classrooms, or WMATA’s formally established interpretations of the written rules and SOPs. 

Further, FTA’s SMI team found that, due to the potential loss in overtime, there is a clear 

financial disincentive for veteran RTCs to support changes in processes and tools that would 

make additional hiring easier. Therefore, FTA’s SMI team found that veteran RTCs have no 

vested interest in training or teaching new RTCs, and, based on the extremely low success rate 

for new RTCs, it is clear that the reliance on on-the-job training has not been effective. 

FTA’s SMI also found that some new RTC trainees struggle with maintaining a complete 

rulebook, updated with all temporary and permanent orders issued since 2014. WMATA 

informed FTA that the agency hopes to issue a new Metrorail rulebook in 2017; currently an 

electronic version is available on WMATA’s intranet which contains the 2014 rulebook and the 

roughly 40 temporary and permanent orders since the 2014 rulebooks was finalized as separate 

PDF files. FTA’s SMI team was unable to find a master assembled and collated electronic 

rulebook, with the temporary and permanent orders inserted into the electronic file. While this is 

not unusual in the rail transit industry, the lack of a collated rulebook has significantly impacted 

RTC trainees from other industries, where updated, assembled copies of rulebooks must be 

maintained at all times, and are used as vital references to govern controller work activity. 

Finally, new RTCs lack the opportunity to participate in emergency drills or exercises. FTA’s 

SMI team found that new RTCs generally had very limited experience with emergency situations 

in the Metrorail environment. WMATA’s development of scripts and written case studies and 

scenarios should further support the training of new RTCs. 

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•	 Finding R-13: WMATA’s accident investigation process does not look at the ROCC 

or individual RTCs, and their potential involvement in the accident under 

investigation. 

FTA also found that WMATA’s accident investigation process, with some exceptions, generally 

does not look at the performance of the ROCC or the individual RTCs, but typically focuses on 

the train operator. For example, most of the accident investigations reviewed by FTA’s SMI 

team and conducted for incidents involving the ROCC do not: 

•	 Include recertification information for RTCs in the accident investigation report. 

•	 Interview RTCs involved in incidents following the same process as used for train 

operators. 

•	 Include transcript of audio recordings in investigation report, and review and assess 

quality of radio communication and radio transmission. 

•	 Include hours of service information for RTCs as well as train operators. 

•	 Make findings regarding the need for hazard analysis if SOPs or rules are changed in 

response to an accident, if SAFE finds that such additional analysis is warranted (outside 

the usual rule revision and update process). 

•	 Include summaries of detailed employee information that is maintained in hard copy at 

the Divisions. 

•	 Include efficiency check and quality check information from Rail Transportation and Rail 

Operations Support, to accompany other information provided by supervisors. 

•	 Review level of coordination between Button and Radio Controllers as standard part of 

report for any incident in which the ROCC is significantly involved. 

FTA’s SMI team finds that in most accident investigations, ROCC management has not 

experienced the same opportunity to learn from mistakes, errors and incidents as other groups 

within Rail Transportation. In this manner, the ROCC has also been largely immune to the 

consequences of accidents to which its members, organization, procedures, practices or training 

programs may have contributed. 

In a few instances, FTA also determined that WMATA had not ensured that RTCs involved in 

incidents were taken for mandatory post-accident drug and alcohol testing as per 49 CFR Part 

655.44. 

•	 Finding R-14: While it has improved, the quality of WMATAs radio system is still 

poor in some locations. 

While WMATA’s digital radio system is clearer than the analog version, there is still major 

distortion and feed-back in the field, and from the ROCC, and a significant number of radio dead 

spots still exist. Many WMATA employees throughout the agency ranked poor radio 

performance as their top safety issue. FTA’s team observed dropped words and communications 

as commonplace occurrences. “I can’t hear you, Central” is a frequent radio transmission from 

the field. 

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Follow-on interviews with WMATA’s Communications Department (COMM) revealed that not 

all locations within the WMATA system are included in the design for radio coverage, including 

fan shafts, vent shafts and emergency evacuation stairwells, refuge areas and elevator shafts, and 

transition areas from above ground to underground coverage including station entrances and 

portal entrances. 

All other locations on the Metrorail system have full radio coverage and any report of a dead 

spot is treated as a system failure and maintenance forces are dispatched to investigate and 

correct the problem. COMM receives approximately three reports a day for radio system “Dead 

Spot” in these covered locations. Representatives from both the ROCC and COMM 

acknowledge that there are a number of improvements that can be made to the radio system to 

enhance system reliability, such as installation of an alarm system on all bidirectional amplifiers 

to allow maintenance forces to respond more rapidly, and replacement of the current tunnel 

antenna cable with a newer higher capacity antenna cable. 

WMATA’s Capital Improvement Plan 136 is underway to address some but not all of the needed 

enhancements. For example, this project is replacing most below-ground radiating coaxial cable 

with higher capacity, bigger cable for less loss, better radio frequency propagation, and more 

capacity. Additional enhancements will require more capital project funding. 

Required	Actions

Safety Directive 15-1 identifies 21 required actions to be taken by WMATA to address safety 

deficiencies in established programs governing ROCC operations, management, training and 

evaluation. 

Metrorail Category 1: Inadequate Rail Operations Control Center Staffing and Procedures 

Findings Required Actions (specified in Safety Directive 15-1) 

Finding R-1 WMATA’s Rail Operations 

Control Center is 

significantly understaffed. 

R-1-1-a WMATA must fully staff the Rail Operations Control Center. 

Finding R-2 RTC re-certification has not 

occurred as required. 

R-1-2-a WMATA must complete and maintain required annual re-certifications 

for Rail Traffic Controllers. 

Finding R-3 RTCs receive limited 

refresher training and no 

road days. 

R-1-3-a WMATA must establish a program to provide each Rail Traffic 

Controller with mandatory road days for territory familiarization and to 

keep up with changing system elements. 

R-1-3-b WMATA must require all Rail Traffic Controllers to obtain and maintain 

Level 4 Roadway Worker Protection training and certification. 

Finding R-4 There is a high level of 

noise and distraction in the 

ROCC, and a lack of 

electronic controls in the 

R-1-4-a WMATA must complete its assessment regarding the identification of 

critical versus non-critical notifications and alarms in the Rail 

Operations Control Center, and options for removing non-critical 

notifications must be implemented. 

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Metrorail Category 1: Inadequate Rail Operations Control Center Staffing and Procedures 

Findings Required Actions (specified in Safety Directive 15-1) 

AIM system to prevent 

errors. 

R-1-4-b WMATA must conduct an engineering assessment, and implement the 

results regarding options to reduce noise in the Rail Operations 

Control Center, including ambient noise and feedback from the radio 

system. 

R-1-4-c Until such time as electronic records of train movement are readily 

available to on-duty Rail Traffic Controllers, WMATA must ensure that 

its Rail Traffic Controllers maintain a paper-based record of all 

mainline train movements, signal by-passes, and unusual movements. 

Finding R-5 WMATA RTCs are required 

to perform many tasks 

outside of industry 

standards. 

R-1-5-a WMATA must ensure Rail Traffic Controller workload and distraction 

do not interfere with the safe and efficient movement of trains. 

Finding R-6 Radio discipline is poor. R-1-6-a WMATA must establish and enforce a proper protocol for language 

and terminology that is used over the radio – to include 100 percent 

word-for-word read-back for safety-related instructions and unusual 

train movements. 

R-1-6-b As part of the radio protocol required in R-1-6-a, WMATA must 

establish an approach for communicating and managing all speed 

restrictions that requires two-way communication between the ROCC 

and train operator and takes full advantage of available electronic AIM 

system features. 

Finding R-7 WMATA’s ROCC lacks 

formal procedures, manuals 

and checklists 

R-1-7-a WMATA must establish procedural checklists for Rail Operations 

Control Center staff to implement the Standard Operating Procedures 

attached to the Metrorail Safety Rules and Procedures Handbook. 

R-1-7-b WMATA must enhance RTC reference materials to direct internal 

operations at the Rail Operations Control Center, including the use of 

the Advanced Information Management system, visual schematics of 

WMATA stations and facilities, and internal ROCC administrative 

policies and procedures. 

Finding R-8 Personal cell phones are 

used by RTCs in the ROCC. 

R-1-8-a WMATA must establish a clear policy that prohibits distractions from 

the use of cell phones and other electronic devices in the Rail 

Operations Control Center. 

Finding R-9 No formal transfer records 

are used when RTCs 

complete shift briefings. 

R-1-9-a Until such time as electronic transfer records are implemented, 

WMATA must ensure that its Rail Traffic Controller use paper-based 

logs with formal signatures. 

Finding R-10 WMATA does not use 

industry standard rules 

reviews and scenario testing 

activities. 

R-1-10-a WMATA must establish an on-going “efficiency” testing program for 

Rail Traffic Controllers to evaluate their in-service performance and 

competency. 

Finding R-11 WMATA faces major 

challenges in recruiting and 

training new RTCs. 

R-1-11-a WMATA must establish an independent committee to evaluate and 

monitor the recruitment of Rail Traffic Controller trainees, the quality 

and performance their training, and the certification of new candidates. 

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Metrorail Category 1: Inadequate Rail Operations Control Center Staffing and Procedures 

Findings Required Actions (specified in Safety Directive 15-1) 

Finding R-12 WMATA’s training program 

for new RTCs is inadequate. 

R-1-12-a WMATA must overhaul, correct, revise and improve its training 

program for Rail Traffic Controllers. 

R-1-12-b WMATA must establish performance standards to be qualified for all 

positions in the Rail Operations Control Center. 

Finding R-13 WMATA’s accident 

investigation process does 

not look at the ROCC or 

individual RTCs. 

R-1-13-a WMATA must expand the focus of its accident investigation process to 

include an active review of the actions of the ROCC, and to ensure 

that RTCs whose performance could have contributed to the accident 

are taken for mandatory post-accident drug and alcohol testing as per 

49 CFR Part 655.44. 

Finding R-14 While it has improved, the 

quality of WMATA’s radio 

system is still poor in some 

locations. 

R-1-14-a WMATA must expedite activities underway to modify the radio system 

design to add coverage to the areas that currently are not part of the 

system design, including tunnel ventilation and fan shafts, safe and 

refuge areas, and tunnel portals. 

R-1-14-b WMATA must assess and prioritize for additional radio enhancements 

not covered by Capital Improvement Plan (CIP) 136. 

5.2	 Category R-2: Ineffective Training, Operational Testing, and Rules 

Compliance Programs 

FTA’s SMI team identified five findings related to the limited availability of training for 

WMATA’s operations and maintenance personnel, and three findings related to WMATA’s 

implementation of operational testing and efficiency check programs for Metrorail personnel. 

Situation

An effective training program for new and existing employees with accurate documentation is 

critical for safe operations. FTA’s SMI team identified specific and potentially serious issues 

related to WMATA’s ability to ensure compliance with critical roadway worker protection 

(RWP) training. Further, FTA’s SMI team found that, while WMATA has developed a series of 

very strong initial training courses for operations and maintenance personnel, there is lack of 

focus on follow-up and refresher training, a lack of resources devoted to training, a lack of 

availability of training, and a lack of strategy for ensuring the technical competence of WMATA 

personnel. 

For many positions, from RTCs to technical specialists in Power, Track, ATC and COMM, the 

overall training is inconsistent and often fragmented, supplemented by on-the-job training from 

veteran personnel who have not been instructed regarding how to provide this training and who 

may not carry out specific tasks or functions exactly as required by WMATA rules and 

procedures. 

Finally, WMATA lacks an efficient recordkeeping system of employee training. 

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•	 Finding R-15: Maintenance and Operations Departments have not ensured the 

RWP training program is being conducted as required. Annual refresher and 

biennial re-certification requirements for Level II and Level IV are behind schedule. 

FTA’s SMI team found that WMATA’s maintenance and operations departments face significant 

challenges in ensuring their personnel are scheduled to receive the required Roadway Worker 

Protection (RWP) refresher and re-certification training. Records produced by WMATA 

indicate that the RWP training program has fallen significantly behind in meeting annual 

requirements for RWP refresher training and biennial requirements for re-certification training 

for Level II and Level IV qualified individuals. 

Based on observations made by members of FTA’s SMI team regarding expired endorsement 

stickers on RWP cards and some confusion among front-line workers in answering questions 

regarding RWP refresher and re-certification training requirements, FTA requested WMATA’s 

records on RWP training. WMATA supplied these records, which show that WMATA is not 

keeping up with refresher training and requalification as required in the RWP Manual and 

Training Program. 

At the time of the SMI, electronic records provided by Technical Skills & Maintenance Training, 

the department responsible for the RWP training program, showed that exactly 2,500 WMATA 

employees had not received the required annual refresher training, and 295 employees had not 

been recertified and/or requalified as specified in WMATA’s RWP Manual and Program. 

However, records kept by individual departments, based on RWP cards issued to employees, 

indicated that the electronic records provided to FTA might not accurately reflect status of 

refresher training and requalification. Some maintenance departments are using photocopies of 

RWP cards to manage separate RWP refresher and requalification tracking systems. 

These photocopy records do not match up with the agency’s official records from Technical 

Skills & Maintenance Training, and generally show a much greater level of conformance with 

WMATA requirements. 

As illustrated in the table below, WMATA has three levels of RWP training and qualification: 

•	 RWP Level I: Restricted Level 

•	 RWP Level II: Limited Access Level 

•	 RWP Level IV: Roadway Worker In Charge 

•	 Note: There is no Level III training 

Each level requires initial training, annual refresher training, and either five-year or two-year 

requalification training. A recertification exam and/or practical must also be completed. 

Refresher training can be provided by an Instructor or through a computer-based training (CBT) 

module. 

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Table 9. RWP Training and Requalification Requirements 

INITIAL TRAINING REFRESHER TRAINING REQUALIFICATION TRAINING 

LEVEL I 1 day Instructor led training 

RWP Access badge issued 

after successful completion 

1⁄2 day Instructor led or Computer-based 

Training (CBT) training each year after Initial 

Training 

RWP badge endorsement sticker is issued 

after each successful completion 

Repeat of Initial Training after 4 years of 

Refresher Training 

RWP Access badge issued after 

successful completion 

LEVEL II 2 days Instructor led training 

RWP Access badge issued 

after successful completion 

1⁄2 day Instructor led or CBT training the year 

after Initial or Requalification Training 

RWP badge endorsement sticker is issued 

after each successful completion 

1 day Instructor led training 

the year after Refresher Training 

RWP Access badge issued after 

successful completion 

LEVEL IV 

Prerequisite: 

Completion of 

Level II & one 

(1) year 

roadway 

experience 

5 days Instructor led training 

RWP Access badge issued 

after successful completion 

1⁄2 day Instructor led or CBT training 

the year after Initial or Requalification 

Training 

RWP badge endorsement sticker is issued 

after each successful completion 

1 or 2 day Instructor led training the year 

after Refresher Training 

RWP Access badge issued after 

successful completion 

WMATA has updated the RWP Manual and Program twice: in May 2012 and June 2014. Major 

changes include: New Cardinal Rule, Update to Good Faith Challenge information, Update to 

Job Safety Briefing information, Update to Watchman location when performing safety role 

(from a place of safety), Update to alternative means of reporting/raising safety concerns that are 

not Roadway specific, and Update to forms of available protection to workers under any type of 

protection (mobile/fixed). 

Without the refresher training, it is unclear how these changes have been communicated to 

WMATA’s employees. The RWP program, which was developed and implemented after eight 

WMATA employees lost their lives in accidents on the ROW between 2005 and 2010, has 

significantly improved safety on the ROW. 

WMATA’s failure to ensure that employees are available for CBT or Instructor-led refresher 

training, and failure to enforce this refresher training as a key eligibility requirement for working 

on WMATA’s ROW (as either a train operator or Maintenance of Way worker) is a serious 

finding, in violation of the first Cardinal Rule in the RWP program: “All employees, regardless 

of rank or title, shall be RWP trained and qualified before entering the Authority Roadway.” 

•	 Finding R-16: Technical training for Operations and Maintenance Departments is 

under-resourced and fractured, currently provided by five different departments 

and IT, is insufficiently directed and resourced, and relies significantly on on-thejob-training (OJT) which is informal and lacks oversight. 

Based on interviews, records reviews, and field observations conducted across several technical 

disciplines, FTA’s SMI team also discovered that there is no enterprise-wide strategy for 

technical training to ensure the proficiency of WMATA personnel, and many gaps exist for 

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operations and maintenance departments. Training is under-resourced and fractured, provided by 

five different WMATA departments and the Department of Information Technology (IT). 

WMATA’s Technical Training Department (TTDC) is currently housed within WMATA’s 

Transit Infrastructure and Engineering Services (TIES) division. Technical Skills & Maintenance 

Training (TSMT), located in Operations Management Services (OPMS), manages WMATA’s 

RWP training program. WMATA’s corporate training department is housed within the Office of 

Talent Management (HRTM) within the Human Resources Department. Rail Operations and 

Quality Training (ROQT), within Rail Transportation (RTRA), trains Rail Operations personnel, 

while Rail Operations Support, also within RTRA certifies operations personnel, and conducts in 

service evaluations. Finally, WMATA’s Safety Department provides certain environmental, 

occupational safety and general safety training courses. 

FTA’s SMI team generally found that while strong technical courses have been developed in 

many areas, there are insufficient resources available to provide enough offerings to adequately 

train and refresh personnel. As a result, there is great reliance on informal, on-the-job training, 

which is not standardized or overseen. Operations personnel do not have adequate training 

facilities (2.5 classrooms), no simulators, and face significant challenges in establishing 

professional service standards, adult learning strategies, and taking advantage of technology to 

bring the field into the classroom. 

For maintenance personnel, while great strides have been made in some areas (elevators and 

escalators, for example), many other areas rely primarily on on-the-job training. FTA’s SMI 

team also found that while initial and advanced technical training for ATC technicians, Power 

branch (POWR) specialists, and Track and Structures (TRST) personnel developed by TTDC has 

been very well received, limited training offerings have created long wait lists. TTDC reports 

that, in some instances, they can only meet 20 to 40 percent of demand for training. 

In other cases, TTDC has been able to address demand, but over a much longer time-frame than 

originally requested by the technical department. The opening of the Silver Line and recent 

retirements in ATC and POWR have exacerbated this challenge for TTDC. Rail Car 

Maintenance personnel and representatives from several other departments also reported a lack 

of qualified personnel to fill shifts to allow maintenance technicians to complete needed training 

in a timely fashion. 

For COMM personnel, technical training has restarted after several years of little or no training 

except for new hires. Approximately 10% to 15% of COMM supervisors and technicians have 

received training; however, this is a branch-wide number, and there are pockets of COMM where 

50 percent or more in a particular unit have received training. Because communications 

technology changes so rapidly, training course curriculum needs to be updated frequently. While 

both TTDC and COMM have considered bringing in outside vendors to provide training, neither 

COMM nor TTDC have the resources available to cover these costs. 

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•	 Finding R-17: WMATA does not have a clear strategy for the development or 

delivery of emergency response training to WMATA’s frontline personnel, or for 

managing the logistical challenges associated with coordinating familiarization 

training with local emergency responders. 

Like with technical training, FTA’s SMI team found that WMATA has not established a clear 

strategy or plan regarding the development and delivery of emergency response training to 

WMATA’s frontline personnel. After the event of September 11, 2001, the Transportation 

Security Administration (TSA) and the Department of Homeland Security (DHS) initially 

provided WMATA with grants and support in developing emergency response plans, tools, 

training, and also in assessing vulnerabilities of operations to security and emergency situations. 

Over the years, however, this funding has become more limited, and WMATA has been forced 

to suspend several key training programs, including its Management Emergency Response 

Training (MERT) program, which provided emergency training for operations managers, 

frontline supervisors and frontline employees. While drills and exercises necessarily include train 

and/or bus operators, field supervisors and the ROCC, these exercises only reach the handful of 

personnel who participate. WMATA has not been able to identify a consistent funding source to 

support on-going emergency preparedness training for frontline personnel. 

The complexity of WMATA’s emergency planning in the National Capital Region necessarily 

limits participation to representatives of WMATA’s Office of Emergency Management or Metro 

Transit Police Department. However, since WMATA’s Rail Operations Training Departments 

are not represented during the emergency planning process, it is very challenging for them to 

know if new rules, temporary and permanent orders, training, and the lessons learned documents 

published by RTRA or RTTO reflect the contents of emergency plans and the understanding of 

local emergency responders. 

FTA’s SMI team found that WMATA’s Office of Emergency Management does not review 

emergency training developed by the Rail Operations Departments, and has no way to know if 

information on emergency management has been effectively communicated to frontline 

employees. WMATA’s Office of Emergency Management does coordinate with the other 

WMATA Departments through the process used to develop and update the Rail and Bus 

Rulebooks, the agency-wide Emergency Operations Plan, the System Safety Program Plan, and 

the Security and Emergency Preparedness Plan. 

While WMATA actively engages its jurisdictional partners in emergency response training, 

including the use of its Emergency Response Training Facility in Landover, Maryland which 

includes a “mock” subway tunnel and an emergency railcar “roll-over” simulator to train fire, 

rescue, police, emergency and transit personnel from Maryland, Virginia and the District of 

Columbia, changing Regional priorities and reductions in grants from DHS and TSA have also 

impacted the agency’s ability to ensure that its partners particularly in the District of Columbia, 

routinely receive familiarization training that covers the critical elements of responding in the 

subway tunnel environment, including management of key passenger communication and tunnel 

ventilation systems. 

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FTA’s SMI team found that since WMATA’s ROCC moved from the Jackson Graham Building 

in downtown Washington, D.C. to the Carmen E. Turner facility in Landover, Maryland, several 

years ago, WMATA has not conducted regular tests at Jackson Graham regarding the capabilities 

of the old ROCC to perform as a back-up control center in the event of an emergency. Use of this 

facility could also potentially support emergency response training and other training of new 

RTCs. 

•	 Finding R-18: Rules compliance checks of operational personnel are inconsistent, 

and an inadequate number of checks are performed. 

To ensure the proficiency, professionalism, and safety of rail transit operations, in addition to an 

on-going training program, rail transit agencies also establish programs to conduct announced 

and unannounced operational testing. FTA’s SMI determined that announced and unannounced 

testing of operational personnel (including train operators, Station Managers, Interlocking 

Operators) at WMATA is not being conducted consistently or effectively. 

Rail Transportation field supervisors are responsible for conducting 60 rules compliance checks 

on station managers and 60 rules compliance checks on train operators each month. As a goal, 

not a requirement, rail transportation field supervisors should check on new rail transit operators 

at least five times per month. 

In reality, FTA’s SMI team found that rail transportation field supervisors only have the 

opportunity to check approximately half of the operators in their field divisions more than once 

per month. In addition, not all train operators are checked every month. Further, new supervisor 

trainees interviewed by FTA’s team were not able to correctly identify the number of required 

field checks or to describe the process they would use to conduct them. 

While rail supervisors have an electronic form that identifies multiple elements to be checked to 

ensure the safety and quality of rail transit operation, they are only required to enter a single 

observation per train operator, as opposed to a complete report. 

Monthly reports generated by Rail Operations Support, the quality control and quality assurance 

division within Rail Transportation, demonstrate rates of between 20% and 40% noncompliance 

when they check for specific safety critical rules related to train berthing, door operation, RWP 

procedure adherence, and speed restrictions. On the other hand, monthly reports compiled by 

rail supervisors for the same areas of rules compliance, looking at the same operating divisions, 

typically demonstrate less than 1% noncompliance. Given that an issue is so rarely identified by 

rail supervisors, FTA questions the accuracy and thoroughness of these reports. 

Due to resource limitations, Rail Operations Support typically only observes between 10 and 50 

train operators each month, with a focus on a specific operating rule or issue. FTA’s independent 

field reviews and observations, conducted during the SMI using WMATA’s standard forms and 

processes, found similar levels of non-compliance in most areas (20% to 40%), though FTA’s 

SMI identified 100% non-compliance with the “5-second” rule, recently implement to support 

train operator situational awareness and prevent wrong-side door openings and inappropriate 

train movements. 

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•	 Finding R-19: Rail Transportation is not ensuring that field supervisors conduct 

required rules compliance checks on station managers and train operators. 

Records pulled from the electronic system used to track the checks performed by rail supervisors 

show significantly decreasing numbers of reports since 2010, when the system was fully 

implemented: 

Year Number of Submissions 

2008 24,480 

2009 107,727 

2010 138,488 

2011 128,348 

2012 104,325 

2013 95,991 

2014 75,358 

2015 (thru March) 12,633 

Total 687,350 

WMATA is transitioning from its current Blackberry electronic reporting system to a new 

Windows-based system, and Blackberries are no longer being issued. In the interim, supervisors 

without Blackberries are not conducting (or at least not reporting) checks. The number of total 

reported rules checks has fallen by almost 50 percent from 2010, while the number of trains in 

service has remained constant or increased with the opening of the Silver Line in 2014. 

WMATA has invested considerable time and resources in a system that does not appear to 

support the agency’s understanding regarding the performance of its train operators. Interviews 

with train operators indicated the while Platform Line Instructors (PLIs) offered very helpful 

feed-back on train operations during initial training, many rail supervisors do not take the time to 

conduct face-to-face meetings with train operators to review their performance, convey 

operational testing results, and discuss potential issues, challenges, or opportunities for 

improvements. 

•	 Finding R-20: New supervisors are not familiar with rules compliance checks 

requirements. 

Field supervisors indicated that they received little training on how to conduct ride checks and no 

training on how to conduct operational testing. Many field supervisors interviewed by FTA’s 

SMI team had not seen or were not aware of the results of monthly assessments compiled to 

document that performance of train operators. 

Finally, FTA’s SMI team found that WMATA has no Heavy Railcar Simulators to support rail 

operator training and evaluation programs. FTA’s SMI team believes that use of this technology 

could greatly improve WMATA’s ability to train, re-train and evaluate train operators, field 

supervisors, and RTCs, especially given the challenges of accessing the ROW for these purposes. 

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This technology has worked very effectively at New York City Transit and other rail transit 

systems. 

•	 Finding R-21: Some newly promoted field supervisors, who have not previously 

operated rail vehicles, are not sufficiently trained to relieve train operators on the 

mainline. 

During interviews and field observations, FTA’s SMI team also found those rail transportation 

supervisors, RTCs and other positions that may have to operate trains or direct train movements 

are not always proficient or confident in mainline train operation. Some newly promoted rail 

supervisors have not operated rail transit vehicles in revenue service previously. Due to limited 

ability to access the mainline, most train operator training takes place in the rail yard. Limited 

vehicle availability (to put service on the Silver Line) further heightens the challenge of 

providing trains for training on the mainline. 

While train operator trainees get extensive on-the-job training with existing train operators to 

build their skills prior to operating service on the mainline, field supervisors and RTCs do not 

(they move on to other training modules). As a result, some field supervisors are fearful and 

hesitant to relieve train operators on the mainline, or to assume operation of the train for any 

reason (since they are held to the same discipline matrix as train operators for any events in 

service). Several train operators informed members of FTA’s SMI team that this situation means 

that the rail supervisors are unwilling to provide them with relief for restroom breaks or other 

personal matters. 

•	 Finding R-22: WMATA must ensure that two-year re-certifications are being 

performed for train operators. 

FTA’s SMI team also followed up with Rail Operations Support regarding the performance of 

the two-year re-certifications required for train operators and interlocking operators. In response 

to FTA’s request, WMATA produced 485 re-certification records for the 14-month period 

January 1, 2014 through February 28, 2015. Based on the total number of train operators and 

interlocking operators, this level of documentation generally conforms to the number that should 

be completed in order for WMATA to maintain the two-year cycle. 

Given the critical importance of this function for ensuring the proficiency of train operators, 

especially in light of other FTA findings regarding weaknesses in rules compliance programs 

discussed above, FTA’s SMI team finds that Rail Operations Support staffing is critical to 

ensuring the on-going completion of this program, and that any reductions in staffing levels 

would impact the ability of the department to complete these re-certifications as required by 

WMATA policy and the System Safety Program Plan. 

Required	Actions

Safety Directive 15-1 identifies 22 required actions to be taken by WMATA to address safety 

deficiencies related to operations and maintenance training and the performance of operational 

testing and rules compliance programs. 

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Metrorail Category 2: Ineffective Training, Operational Testing and Rules Compliance Programs 

Findings Required Actions (Specified in Safety Directive 15-1) 

Finding R-15 Maintenance and 

Operations Departments 

have not ensured the RWP 

training program is being 

conducted as required. 

Annual refresher and 

biennial re-certification 

requirements for Level II 

and Level IV are behind 

schedule. 

R-2-15-a Each WMATA Department with Roadway Worker Protection-trained 

and qualified employees must coordinate with Technical Skills & 

Maintenance Training to get or establish an accurate status on each 

employee’s refresher and requalification training. 

R-2-15-b Each WMATA employee with lapsed refresher training or 

requalification must repeat the initial training and qualification for his or 

her level as specified in WMATA’s roadway worker protection training 

program. 

R-2-15-c WMATA’s Information Technology Department must work with 

Technical Skills & Maintenance Training to develop a long-term 

solution to tracking employee status and ensuring that ComputerBased Training records, classroom records and employee records are 

accessible to all departments. 

R-2-15-d WMATA must include annual Roadway Worker Protection refresher 

and requalification time in overall work scheduling protocols and 

requirements. 

Finding R-16 Technical Training for 

operations and maintenance 

departments is underresourced and fractured, 

currently provided by five 

different departments and 

IT, is insufficiently directed 

and resourced, and relies 

significantly on on-the-jobtraining (OJT) which is 

informal and lacks 

oversight. 

R-2-16-a WMATA must conduct a coordinated study to prioritize technical 

training needs for maintenance personnel, and operations training for 

Rail Traffic Controller, Train Operators, and Field Supervisors. 

R-2-16-b WMATA must evaluate whether re-organization or consolidation of 

training functions would improve the agency’s ability to manage, 

schedule, budget for, develop, oversee and assess training and ensure 

that training material remains up-to-date. 

R-2-16-c WMATA must establish a comprehensive training program to 

communicate the new “Fire Life Safety 1000 -- Inspection, Testing and 

Maintenance Procedure” to WMATA Operations and Maintenance 

personnel. 

R-2-16-d WMATA must establish formal guidance for maintenance employees 

responsible for providing on-the-job training. 

Finding R-17 WMATA does not have a 

clear strategy for the 

development or delivery of 

emergency response 

training to WMATA’s 

frontline personnel, or for 

managing the logistical 

challenges associated with 

coordinating familiarization 

training with local 

emergency responders. 

R-2-17-a WMATA’s Office of Emergency Management must conduct a formal 

review of the Metrorail Safety Rules and Procedures Handbook, the 

supporting Standard operating Procedures, and the new checklists, 

tools and desk references developed by the Rail Operations Control 

Center to ensure conformance with WMATA’s emergency plans and 

the understanding of local jurisdictions as reflected in region-wide 

emergency operations plans. 

R-2-17-b WMATA’s Office of Emergency Management must conduct a formal 

review of all training provided to frontline, supervisory and ROCC 

personnel regarding the actions required to be performed during an 

emergency to ensure its conformance with WMATA’s emergency plans 

and the understanding of local jurisdictions as reflected in region-wide 

emergency operations plans. 

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Metrorail Category 2: Ineffective Training, Operational Testing and Rules Compliance Programs 

Findings Required Actions (Specified in Safety Directive 15-1) 

R-2-17-c WMATA must establish an approach for delivering updated emergency 

response training to front-line Train Operators, Supervisors, Stations 

Managers, Rail Traffic Controllers, and other personnel. 

R-2-17-d WMATA must review and update its approach to providing 

familiarization training to local emergency responders, and ensure that 

emergency responders have ample opportunities to learn and practice 

activating and using fire life safety equipment and systems, including 

ventilation fans, fire suppression system, standpipes, communication 

equipment, and other systems. 

R-2-17-e WMATA must test its backup Rail Operations Control Center on a 

quarterly basis and demonstrate the ability to safely control train traffic. 

Finding R-18 Rules compliance checks of 

operational personnel are 

inconsistent. 

R-2-18-a WMATA must require Rail Supervisors to complete meaningful rules 

checks on Train Operators, not just single observation items, unless 

directed as part of a special emphasis program. 

R-2-18-b WMATA must establish documentation and a training program to 

ensure that Rail Supervisors know how to conduct and record 

meaningful rules checks of Train Operators, and how to discuss results 

with Train Operators. 

Finding R-19 Rail Transportation is not 

ensuring that field 

supervisors conduct 

required rules compliance 

checks on station managers 

and train operators. 

R-2-19-a WMATA must develop a formal operations testing program to include 

active, fail-safe testing of all employees responsible for operating or 

directing the safe movement of trains. 

R-2-19-b WMATA must document operational testing requirements and test 

results to improve the utility of the program as part of a robust testing 

and observation program. 

Finding R-20 New supervisors are not 

familiar with rules 

compliance checks 

requirements. 

R-2-20-a WMATA must improve the quality and consistency of training for new 

Rail Supervisors to include purpose and requirements for rules checks. 

Finding R-21 Some newly promoted Field 

Supervisors, who have not 

previously operated rail 

vehicles, are not sufficiently 

trained to relieve train 

operators on the mainline. 

R-2-21-a WMATA must establish a minimum number of trips per month that 

each Rail Supervisor must complete on the mainline to ensure the 

sufficiency of his or her skills. 

R-2-21-b WMATA must review Supervisor Daily Activity Reports to ensure that 

Supervisors are completing required activities, including the minimum 

number of established trips per month. 

Finding R-22 WMATA must ensure that 

two-year re-certifications are 

being performed for Train 

Operators. 

R-2-22-a WMATA must review its schedule of in service evaluations to ensure 

sufficient time is available for each Train Operator to receive his or her 

two-year re-certification. 

R-2-22-b WMATA’s Information Technology Department must work Rail 

Operations Support to develop a long-term solution to tracking Train 

Operator re-certification status and the results of any other in service 

examinations or activities completed. 

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5.3 Category R-3: Insufficient Track Time for Maintenance 

Average weekday Metrorail ridership has fallen from a high of 750,431 in 2008 to 721,804 in 

2014 (not counting the Silver Line Extension to Tysons Corner). Since 2012, WMATA has 

worked to encourage riders “at all times of day, making all kinds of trips”2 not just rush hour 

commuting. These policies, which keep trains on the tracks later in the evening and with greater 

frequency through the weekends, holidays, and in support of special events, are occurring at a 

time when the maintenance demands of aging equipment and deteriorating infrastructure are 

increasing. Further, with the expansion of the Silver Line, WMATA now has more trains in 

service than at any time in its history, and more equipment and infrastructure to be maintained. 

Situation

Over the last decade, WMATA has operated its service with extremely tight track maintenance 

windows. Closed from midnight to 5 a.m. on weekdays, and from 3 a.m. to 7 a.m. on Friday and 

Saturday nights, WMATA provides maintenance departments with limited nighttime (OWL) 

access to track and wayside equipment. WMATA also performs maintenance work during offpeak periods. With only two tracks, shared by multiple Metrorail lines in the downtown core of 

the system, WMATA does not have the option, available for some peer rail transit systems, to reroute passenger service around maintenance work zones using a third or fourth track. 

Key WMATA maintenance departments with responsibilities on the rail ROW, such as Track 

and Structures, POWR, ATC, and COMM, generally perform corrective maintenance and repairs 

during the OWL shift. Inspections and testing to ensure the safe condition and performance of 

infrastructure elements are conducted during off-peak service (typically 10:00 a.m. to 2:00 p.m.). 

Specific rehabilitation, replacement or restoration projects may be conducted with or without 

contractor support during the OWL shift, during “early outs” (periods where service may be 

stopped or limited to 20-30 minute headways beginning at 10:00 p.m. on a specific portion of a 

Metrorail line), through weekend shutdowns (where a specific station or section of a station may 

be shut-down during the weekend), and during holiday weekend work shutdowns (when a 

significant portion of a Metrorail line is shutdown for a 2-day or 3-day holiday weekend, and 

coordinated work is performed across many maintenance departments to rehabilitate, repair, test, 

and thoroughly clean the rail system infrastructure). 

WMATA also can initiate single-tracking at any time, to manage emergency repairs or scheduled 

maintenance, or in support of “early outs” and shutdowns. Using interlockings, crossovers and 

pocket tracks, single-tracking options configure routes so trains in both directions share the same 

track, providing maintenance personnel with access to the out-of-service track. 

2 http://www.wmata.com/about_metro/board_of_directors/board_docs/100914_4BCombinedColor.pdf 

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•	 Finding R-23: Current OWL nighttime maintenance window typically allows 

between 90 minutes and two hours of on track time to complete work. 

Interviews, field observations and records reviews show that many of the most significant 

challenges to WMATA’s maintenance program stem from shrinking access to the track during 

OWL service; increasing limitations in “early-outs”, weekend and holiday shutdowns; and 

reductions in the use of single-tracking to support scheduled maintenance. In interviews, records 

reviews, and field observations of WMATA’s evening and late night/early morning maintenance 

activities, FTA’s SMI team found that on most nights, WMATA work crews responsible for 

maintaining critical Metrorail system components, including track, traction power, signal and 

train control, communications systems, and other structural elements, have between 90 minutes 

and two hours of actual track time during which to perform work. 

According to interviews with WMATA maintenance personnel, this situation represents a 

decrease from the track time previously available for work prior to 2012. Given the poor state of 

repair of some system components, many WMATA maintenance managers indicated they do not 

consider even three hours of track time per evening sufficient for a two-track system providing 

WMATA’s level of service. Veteran maintenance employees reported their frustration and 

concern at watching the window of available time on track tighten over their careers from six 

hours per night when the system was new, to four-to-five hours through the early 2000s, to threeto-four hours until the last few years, where it has now fallen, on some nights, below two hours, 

while the condition and performance of the system worsens. FTA’s SMI team generally found 

that maintenance employees at all levels of the WMATA organization, from the front-line to 

senior management, identified the limited maintenance window as their single biggest safety 

challenge. 

FTA’s SMI team observed OWL shift work on March 23 (into the morning on March 24) and on 

March 24 (into the morning of March 25). On the March 23 OWL shift, for what should have 

been a simple T-bar replacement, and with the heightened scrutiny due to the presence of FTA’s 

SMI team, the contractor was still not able to get access onto the work site until 2:00 a.m., and 

the contractor had to start clearing the site at 4:00 a.m., leaving only two hours of productive 

time. Interviews with WMATA personnel on the site indicated that sometimes contractors do not 

access the work site until 2:30 a.m. and still must begin clearing at 4:00 a.m. The impacts of this 

limited work window can be exacerbated by communication and logistical challenges. For 

example, during the course of the T-bar replacement observed by FTA’s SMI team, it became 

clear that the Power branch work crew had the wrong size T-bar. The T-bar connects to power 

and ATC cables, however, ATC personnel were not on the job site, and there was confusion 

whether the ATC department had been consulted in the planning of the work. Since there was no 

time to bring new parts or personnel to the work site, or to complete a field modification, the 

original equipment had to be restored for revenue service, and no actual replacement work was 

accomplished in this location. 

On the March 24 OWL shift, FTA observed the performance of interlocking testing conducted 

by the ATC department under emergency rights established in WMATA's General Order and 

Track Rights System (GOTRS). Due to the priority in GOTRS, testing began at approximately 

1:15 a.m. at the Largo interlocking and concluded around 4:00 a.m. Five total tests were 

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scheduled as part of the biennial testing program for the interlocking. Four sets of tests generally 

proceeded as required (traffic locking, approach and time locking and signal indication locking, 

switch detector and route locking, and wayside push button boxes); however, there was 

insufficient time for ATC personnel to complete the fifth test (time release, timing relays and 

timing devices), which had to be re-scheduled. While at the interlocking, FTA’s SMI team 

observed two track locations in extremely poor condition; the first site had missing third rail 

cover boards with an accumulation of detached vehicle "shoes" at a wayside pushbutton location, 

and the second site had loose wedges on Switch 1B on Track 2, which allowed the switch to 

move under reverse train movements. 

While these items were reported to the Maintenance Operations Center, and work orders were 

issued for their repair, interviews with ATC and Track personnel, and reviews of inspection and 

maintenance records, indicate that it is difficult for Track personnel, under the current track 

allocation schedule, to get sufficient access to interlockings to conduct routine maintenance 

which would improve their general condition. For example, the signal supervisor at the Largo 

interlocking had previously reported similar conditions. 

While WMATA’s executive leadership team reports that new work processes, machinery and 

equipment have improved the agency’s production per time rate, and that less work now has to 

be performed in specific areas, such as tie replacement or for rehabilitation projects that have 

already been completed on a given line, than during the 2010 to 2012 time period, FTA’s SMI 

team found that limited track time creates numerous challenges for WMATA’s maintenance 

departments and for safe condition of WMATA’s critical track, power and ATC infrastructure. 

•	 Finding R-24: WMATA has reduced other options for track access, including 

holiday weekend work shut-downs, early outs, and single-tracking. 

FTA’s SMI team also discovered that maintenance opportunities formerly available through 

other means, such as holiday weekend work shut-downs, early outs, and single-tracking, have 

also been cut back in an effort to expand service and reduce customer inconvenience. For 

example, in 2014 and so far in 2015, the number of holiday weekend shutdown days available 

for maintenance has been reduced from 9 days per year (3, three-day shutdowns per year) to 4 

days per year (2, two-day shutdowns). New limitations were placed on early outs and singletracking, due to service expansion for special events at the National Mall, Nationals Park, Wolf 

Trap, FedEx Field, Verizon Center, RFK Stadium, Patriot Center, Smith Center, Strathmore, and 

holiday events. During the month of December, early outs and single-tracking were effectively 

stopped altogether on several lines to support holiday shopping and events throughout the 

national capital region. 

During a presentation to the WMATA Board of Directors in October 2014, limiting and 

suspending trackwork was presented as a positive action to increase ridership. Information 

presented to the Board of Directors included the following language relating to the impact of 

further reductions in trackwork: 

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“As reported previously, Metro has reduced the intensity of weekend trackwork closures. 

Customers have noticed and responded, and weekend ridership has increased in recent 

months. We expect this trend to continue.” 3 

WMATA’s commitment to serve its customers with extended Metrorail service for special 

events and weekend activities comes with a corresponding and significant impact on the 

condition and performance of the Metrorail system, and potentially the safety of critical 

infrastructure components. 

•	 Finding R-25: Due to lack of track time, WMATA’s maintenance departments must 

consistently re-schedule work, and, as a result, have growing maintenance backlogs, 

dating back to 2012 and 2013. 

As a result of the shrinking maintenance window, records show that up to 30 percent of planned 

maintenance work must be re-scheduled due to lack of track access. As a direct consequence, 

WMATA’s maintenance departments collectively have accumulated thousands of backlogged 

work orders dating back to 2012 and 2013. Lack of track access has left WMATA’s 

maintenance managers struggling to prioritize the most significant and safety critical repairs for 

completion, while deferring and re-scheduling most other work. 

For example, WMATA’s Track and Structures department addresses all Black, Red or Yellow 

conditions (Priority 1 Defects) that impact the speed of trains as a priority. Generally, Track and 

Structures personnel are able to address these items in a timely manner (2 hours to 1 week). A 

daily speed restriction report is distributed to monitor what Priority 1 defects are still current and 

which defects have been cleared. 

However, between January 1, 2012, and February 18, 2015, the Track and Structures Department 

also issued 3,263 work orders for Priority 2 Defects that still remain open. Priority 2 defects do 

not require speed restrictions, but do require repair. Typical items include battered rail, wheel 

burns on rail, side wear, top wear, minor chipping, corrugation, missing third rail cover boards, 

and leaks. Priority 2 defects also must be constantly monitored because, individually, or in 

combination at a specific location, they can escalate into Priority 1 conditions that require speed 

restrictions. 

The graphic below highlights the number of open work orders remaining for Priority 2 defects 

since 2012. 

3 Please see: http://www.wmata.com/about_metro/board_of_directors/board_docs/100914_4BCombinedColor.pdf. 

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TRST OPEN WORK ORDER FAILURE DETAIL REPORT
%

CHART
%

Final Report – Safety	 as of 2/18/2015 WOPriority = 2 Management Inspection

Washington	Metropolitan	Area	Transit Authority

WMATA Track and Structures Open Work Order Defects, 2012 through 2015 

542

2012

653

2013

1601

2014

467

2015

Open Defects Workorder Chart 

2012 542 16.6%

2013 653 20.0%

2014 1601 49.1%

2015 467 14.3%

Total: 3263 100.0%

Track and Structures management indicated that additional access to specific locations, provided 

through reductions in restrictions on single-tracking during off-peak service and late night hours, 

would enable track maintenance personnel to begin to address this backlog. On-going rail 

replacement (about 12 miles per year) also supports improvements in the condition of track. 

FTA’s SMI team also determined that WMATA’s Power branch, within the Office of System 

Maintenance, has over 1,700 open work orders, dating back to 2012, largely as a result of limited 

track access. WMATA’s Power branch adds between 15 and 30 new open work orders to this 

total each month. These work orders relate to traction power substations and tiebreaker stations, 

including transformers, rectifiers and switchgear, cables, insulators, as well as the electrification 

systems for critical drainage pumping stations, ventilation fans and equipment, communications 

systems, emergency power systems, and lighting. To tackle this growing list of open work 

orders, and to keep current moving forward, Power branch managers estimate that a 10-15% 

increase in staffing is required to accommodate the work load. 

Due to the emergency nature of many repairs to the ATC system, and their critical importance to 

passenger operations, FTA’s SMI team found only 173 open ATC work orders in WMATA’s 

maintenance information management system. However, the ATC department has struggled 

with completion of its track circuit replacement program, falling significantly behind schedule, in 

part due to the challenges of obtaining track time for their staff and contractor personnel, which 

has increased the cost of the overall track circuit replacement program. In addition, ATC 

managers have been unable to complete certain types of cable replacement activities. These 

issues will be discussed in the next section of this report. 

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Finally, at the time of FTA’s SMI, COMM had 380 open work orders in the system. Most of 

these work orders related to alarms received in the ROCC from the AIM system. While charged 

with the responsibility to investigate and resolve AIM system alarms, COMM faces significant 

challenges in getting track time to re-create the conditions that might have triggered the alarm. 

For example, failures that occurred under eight-car train conditions in peak service may not 

replicate under lower power levels in off-peak service or late at night. 

•	 Finding R-26: Efficiencies can be obtained to improve the way in which WMATA’s 

workers and contractors currently access the ROW. 

While there are many challenges involved in accessing the ROW with the personnel and 

equipment required to perform work, members of FTA’s SMI team observed that the process to 

remove third rail power and bring equipment to the work site involved multiple delays from the 

ROCC, in waiting for authorized movements and activities. FTA noted that, during all OWL 

observations, appropriate work safety rules were adhered to and the work site was properly set 

up with lanterns, track jumpers and monitoring devices. 

However, as discussed in greater detail earlier in this report, FTA’s SMI team also believes that 

WMATA’s ROCC can maintain safety while increasing field productivity. For example, the 

approach taken by the ROCC to bringing down power each evening, and restoring power in the 

early morning, could be improved through the use of a Power Director position (like many of 

WMATA’s peers), less distraction for controllers and dispatchers, better radio discipline, and 

better training. 

FTA’s SMI team also recognizes that WMATA’s management of logistics and scheduling to 

ensure efficient and effective use of the available track time could be improved. In environments 

of limited track access, larger, extremely well-managed crews working together in the same 

location to complete multiple tasks simultaneously may offer the best solution to balance 

operational and infrastructure needs. This type of work planning, scheduling and management 

requires considerable integration and coordination across departments, contracts, and with the 

Rail Operations Control Center. 

Interviews with maintenance supervisors and managers in WMATA’s TIES department 

highlighted the impacts of later service and less track access. TIES managers have taken steps to 

survey key work sites prior to conducting the work to ensure as built drawings are current, 

manuals are available, the work site is appropriately setup, and that updates to drawings/manuals 

uploaded to WMATA’s document storage system. TIES also coordinates with the Rail 

Operations Control Center to support earlier start times (10 p.m.) in locations that do not require 

track access (offsite TPSS, tie breaker rooms, etc.). 

However, TIES reports that, other than for emergency maintenance situations that impact 

revenue service, the ROCC does not generally prioritize maintenance work to ensure the most 

effective schedule or implementation, i.e., work could be prioritized by quickest to setup, work 

that needs longer period to conduct, etc. instead of by the discretion of controllers in the Rail 

Operations Control Center. Also, TIES managers pointed out that only one person represents all 

of the maintenance disciplines in the Maintenance Operations Center. This single position 

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coordinates all maintenance activity with the Rail Traffic Controllers during the OWL shift, so 

decisions are not made to maximize the ability of multiple work crews from multiple 

departments to complete objectives during the limited track time. 

Required	Actions

Years of underfunding and tremendous regional growth have resulted in underinvestment and 

significant deterioration Metrorail’s core transit infrastructure and assets over the last decade. 

However, while WMATA has developed and launched new initiatives, including billions of 

dollars in projects under MetroForward and Momentum, to bring the system into a better state of 

repair, without the ability to access to the ROW to make repairs and enhancements, it is unlikely 

that these initiatives will deliver the intended results. Ultimately, FTA’s SMI team finds that 

WMATA must establish a better balance between maintenance work and customer convenience. 

Safety Directive 15-1 identifies four required actions to be taken by WMATA to address findings 

made regarding track time available for maintenance activities: 

Metrorail Category 3: Insufficient Track Time for Maintenance 

Findings Required Actions (Specified in Safety Directive 15-1) 

Finding R-23 Current OWL nighttime 

maintenance window typically 

only allows between 90 

minutes and two hours of on 

track time. 

R-3-23-a WMATA must ensure that a process is in place for identifying and 

scheduling sufficient track time to complete required inspection, 

testing and maintenance activities. 

Finding R-24 WMATA has reduced other 

options for track access, 

including holiday weekend 

work shut-downs, early outs, 

and single-tracking. 

R-3-24-a WMATA must establish firm limits on minimum track time for 

inspection, testing and maintenance activities per month, and revisit 

limits annually. 

Finding R-25 Due to lack of track time, 

WMATA’s maintenance 

departments must consistently 

re-schedule work, and, as a 

result, have growing 

maintenance backlogs, dating 

back to 2012 and 2013 

R-3-25-a WMATA must develop and implement staffing plans to eliminate 

maintenance work orders backlogs and manage on-going workload 

in track and structures, traction power, communications, and 

automated train control departments. 

Finding R-26 Efficiencies can be obtained to 

improve the way in which 

WMATA’s workers and 

contractors currently access 

the right-of-way. 

R-3-26-a WMATA must improve interdepartmental coordination and 

communication to take full advantage of track time. 

5.4 Category R-4: System-wide Maintenance Issues 

FTA’s SMI team identified seven findings related to the performance of maintenance activities 

on the Metrorail system. 

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Situation

WMATA’s TIES department includes 13 offices that are responsible for the engineering and 

maintenance of all Metrorail infrastructure and vehicles. TIES develops and oversees the 

maintenance staffing and programs implemented by TRST; Systems Maintenance (SMNT), 

including the ATC branch, the POWR branch, the COMM branch, the Automatic Fare 

Collection (AFC) branch, and the Storerooms and Material Logistics Shop (SAMS); CMNT; 

ELES; as well as supporting information and procedures from CENI and CENV. 

In addition to maintenance projects and facilities that support on-going operations, coordinated 

through the Office of Major Capital Projects (MCAP), TIES also manages WMATA’s Office of 

Capital Program Delivery (CPDO), including new capital improvement projects managed 

through the offices of Infrastructure Renewal Programs (IRPG), System Renewal Program 

(SRPG), and Track Allocation and Support Services (TASS). 

WMATA’s Plant Department (PLNT) is responsible for maintaining all WMATA facilities and 

grounds, including building repairs, minor concrete and asphalt repairs, maintaining tiles in 

stations, providing system-wide custodial services and landscaping services, maintaining 

signage, managing the station rehabilitation program, maintaining mechanical equipment 

systems, including the fire/life safety systems (fire suppression, tunnel ventilation fans), drainage 

pumping stations, wet and dry sprinklers, and emergency exits. PLNT also coordinates and 

implements WMATA’s response to severe weather incidents. 

WMATA has established a comprehensive program of preventive maintenance and inspection 

procedures. FTA’s SMI team reviewed the staffing and implementation of maintenance 

procedures and programs with WMATA maintenance employees in the field. Interviews, field 

observations and records reviews confirmed that, in the absence of regulated safety standards, 

WMATA maintenance and engineering departments generally adopt voluntary industry 

standards and practices, such as those developed by APTA and the American Railway 

Engineering and Maintenance-of-Way Association (AREMA), and recommendations and 

requirements from Original Equipment Manufacturers (OEM). 

In response to incidents, changes in performance or requirements, or changes in suppliers or 

available parts, WMATA’s engineering team develops engineering modification instructions, 

which are then incorporated into procedures, bulletins, instructions provided to maintenance 

workers and contractors performing work. WMATA maintains a comprehensive set of design 

criteria, and has an established configuration management and safety certification process. 

•	 Finding R-27: Documented maintenance procedures and standard operating 

procedures are not implemented as required. 

WMATA maintenance departments make a general effort to comply with all required inspection 

schedules. Overall, FTA found much evidence regarding a high level of general conformance 

with inspection schedules. However, in specific instances, FTA’s SMI team also found that, due 

to ROW access limitations, staffing limitations, or coordination challenges in working with other 

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departments or divisions, such as the ROCC, scheduled preventive maintenance activities or 

inspections had been missed or fallen behind. 

For example, on March 23, 2015, FTA’s SMI team found during a review of the test records in a 

specific Train Control Room that test ATC3004 - Wayside Inspection - a quarterly test, was last 

recorded as being performed in June 2014, nine months earlier. As another example, FTAs SMI 

team observed that periodic inspection procedures for Rail Car Maintenance require that 

undercar chemical solution cleaning be performed on collector assemblies, friction brake discs, 

shock absorbers, vertical link assemblies, gear boxes and other apparatus. However, trucks that 

were sent to Brentwood Shop for repair and overhaul had a buildup of grease indicating that the 

undercar cleaning process was deficient in some areas. FTA’s SMI team also noticed poor track 

and switch conditions in interlockings, water and drainage issues on track on part of the Red 

Line, and an accumulation of dust and grime in ventilation shafts, as well as a level of 

accumulated dust and grime on third rail insulators that would seem to indicate that not all basic 

elements of inspection or maintenance activity were performed as required. 

FTA’s SMI team also found during an ATC interlocking test that testers did not have the latest 

version of the test procedures (2013 version instead of 2014), and that the procedures call for 

measuring voltages, but do not provide the acceptable range of values. The tester used a 

guideline of approving results within 10% of the reading from the prior test. However, a check of 

prior records for the cab signal transmit level test found that the 2014 test level was almost 100% 

higher than the test in 2015 and the previous 2013 test. This clearly is not within the acceptable 

parameters of the test. 

In another example, in observing contract work on the OWL shift, FTA’s SMI team found some 

general confusion over who was responsible for inspecting and approving the contractor's work 

prior to returning it to revenue service. While inspectors are responsible for ensuring contractor 

work is sufficient, FTA’s SMI team did not observe inspectors at any sites reviewed as part of 

the SMI. Further, after observing a few poorly planned or performed work elements involving 

POWR and ATC contractors, several representatives who spoke with FTA’s SMI team indicated 

that contractor quality is a concern, and contractors are sometimes required to partially reconduct work that was already completed, including the need for escort and track access again. 

• Finding R-28: Walking track inspection resources have been cut in half. 

Track inspectors who spoke with members of FTA’s SMI team voiced concern that after an 

NTSB hearing into a November 30, 2006, accident in which two trackwalkers were struck and 

killed near Eisenhower Avenue Station, WMATA changed its policy regarding two-men track 

walking crews. WMATA determined that one of the two trackwalkers would be converted to a 

watchman position, while the other trackwalker would conduct track inspections. 

Track inspectors noted that this decision effectively cut the track inspection capability of each 2-

man team in half without changing the responsibilities or procedures in any other meaningful 

way. Track inspectors feel that they cannot adequately inspect both running rails and third rail in 

the time allotted with one track walker, and they strongly recommend the reintroduction of a 2-

man track walker team along with a watchman to enhance the inspection process. Track 

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department managers acknowledged the challenges of balancing the safety of workers with the 

safety of the condition of the track. The earlier pilot program with flaggers for 2-man track 

inspection crews was discontinued due to lack of funding. 

•	 Finding R-29: All ATC alarms and issues must be communicated to ATC for 

investigation, repair and analysis. 

The NTSB has closed all safety recommendations issued to WMATA in the wake of the 2009 

Fort Totten collision directly related to ATC. Specifically to respond to the NTSB, WMATA 

completed an extensive system safety analysis of the entire ATC system, commenced a program 

to replace all Alstom Generation II track circuits, greatly enhanced the use of its Track Circuit 

Monitoring Tool, established a Loss of Shunt alarm detection system in the ROCC, and 

established new inspection and maintenance procedures (ATC-1000, 2000 and 3000). 

These actions significantly reduced the number of loss of shunt incidents, including alarms, 

temporary instances of bobbing and actual events, from over 400 per day to approximately 3 per 

day. While loss of shunt (LOS) events still occur on the WMATA train control system, FTA 

finds that WMATA has come in-line with its rail transit agency peers in terms of the number of 

these events. LOS in the rail transit industry can occur for a wide range of reasons, including 

rusty rails, leaves on tracks, arcing, and unbalanced negative return currents in the running rails. 

WMATA continues to use its track circuit monitoring algorithm to review the performance of the 

system and to identify the more significant LOS occurrences in real-time at the ROCC. 

WMATA’s ATC unit works to identify and correct the conditions that cause the LOS events and 

reduce the number of alarms at ROCC. ATC coordinates more closely with other departments, 

such as POWR, on negative return issues and traction power sub-station cable replacement 

programs, which also can affect LOS occurrences. 

During interviews with ATC personnel, it became apparent that there were issues regarding how 

ATC alarms are communicated from the ROCC. Namely, FTA’s SMI team discovered that the 

ROCC does not always open a work order on an ATC alarm or issue, if the RTC or MOC desk 

personnel believe that ATC is already aware of the issue. For example, during the SMI, ATC 

managers were not aware of two recurring non-vital ATC alarms that representatives at 

WMATA’s ROCC stated “are known to everyone” and so were not reported through formal 

work orders. ATC appreciates that ROCC still receives a high number of alarms. The fact that 

the IT department, and not ATC or CENI manages the AIM system, may contribute to the 

problem. ATC managers believe that responsibilities for the AIM system should be transferred to 

the Engineering Department. 

•	 Finding R-30: WMATA’s program for measuring, documenting and addressing the 

potential impacts of stray negative return current on the condition of WMATA’s 

infrastructure is not documented in a formal plan to ensure coordination across 

departments and contractor services. 

WMATA implements an industry best practice by conducting quarterly Thermographic Image 

Testing of the entire traction power distribution system. This testing assists WMATA POWR 

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personnel in locating “hot spots” in the traction power system for review, investigation, 

maintenance or repair. WMATA also has a specialty contractor that performs corrosion surveys, 

track to earth testing, and rail to earth testing, to determine the extent of stray current presence 

and to prepare mitigation strategy reports including recommendations to repair or replace items 

as necessary to limit stray current activity. 

These practices greatly strengthen WMATA’s ability to identify and address the impacts of stray 

current based on the results of findings from testing and surveys, and to address corrosion caused 

by electrolysis. While FTA’s SMI team recognizes many of these tools as industry best practices, 

interviews with POWR personnel indicated that critical coordination and planning activities 

required to ensure that all results from these surveys and tests performed by contractors are 

addressed could be enhanced, and that planning in place to incorporate “stray current” findings 

and mitigations into new projects and on-going maintenance activities could be improved. 

WMATA’s Electrical Mechanical Engineering unit is of the opinion that stray negative return 

currents are one of the primary causes of power-related smoke conditions and deficient track 

conditions. WMATA’s ATC units also report concerns regarding the impacts of stray negative 

return current on the performance of the signal and train control system. The aging of 

WMATA’s infrastructure, and the increasing current draw required to operated 8-car trains has 

likely increased this problem. 

FTA’s SMI team was not supplied with a formal plan that identifies all of the activities that 

WMATA is taking across departments and with contractors to monitor the impacts of stray 

negative return on their maintenance needs and to ensure that findings and mitigation strategies 

are fully integrated into on-going maintenance, procurement, and new project requirements. 

• Finding R-31: ATC resource challenges potentially impact service expansion. 

FTA’s SMI team discovered staffing challenges in the ATC unit due to the recent retirements of 

10 ATC supervisors and the challenges of training new personnel for the Silver Line. FTA also 

found differing perspectives within WMATA regarding the appropriate staffing level for the 

ATC unit. Assistant superintendents and supervisors within the ATC unit reported to FTA that 

because they did not receive approval for sufficient positions to staff the Silver Line, they have 

had to assign the positions allocated for WMATA’s fatigue management program to the Silver 

Line to staff the new line, and their personnel are still working long hours. WMATA’s executive 

leadership team disagreed that additional positions were needed, and pointed out that overall 

staffing in ATC’s home department of System Maintenance has increased by over 150 positions 

for the Silver Line. These increases were shared across the ATC, POWR, COMM, and AFC 

units. 

The recent retirements in the ATC unit, which were not managed with a formal contingency or 

succession plan, have led to a major loss of experience and knowledge in the unit. New hires 

coming into the unit have the required licenses or certifications for ATC technicians, but still 

require specific training modules and on-the-job training to work on specific pieces of WMATA 

equipment in an independent capacity. At the current time, while WMATA’s ATC training 

program is technically strong, due to resource constraints, there are limited offerings of required 

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courses. For example, FTA’s SMI team found that less than 15% of ATC staff has received 

training on the new Silver Line ATC. While this training was sufficient to cover the first job pick 

among ATC technicians, as a result of the most recent job pick, four technicians were working 

on the Silver Line who had not received training. At the time of the SMI, ATC was working to 

address this issue, and ensure that these individuals received the required training. 

FTA’s SMI team also found that with the retirements and limitations in training required for 

advancement, available ATC personnel interviewed in several different field locations reported 

working longer hours. 

•	 Finding R-32: WMATA has no formal program for reviewing the proficiency of 

maintenance field staff. 

Across a variety of WMATA Maintenance Departments, there is no formal program for 

reviewing the proficiency of field staff. Job posting requirements and WMATA’s extensive 

hiring and screening processes ensure that maintenance personnel are certified, licensed or 

accredited as required for their discipline or craft when they are hired into WMATA. WMATA 

also tracks employee activity to maintain required certifications, licenses and accreditations. 

However, while WMATA maintenance personnel meet the requirements to practice their general 

disciplines or crafts (i.e., electrician, electronics technician, mechanic, carpenter, plumber, etc.), 

they are not formally evaluated for their proficiency in working on WMATA systems and 

equipment. With exceptions, such as for high-voltage technicians and the operators of specific 

on-track equipment, examinations are generally limited to individuals seeking to qualify for 

promotions. Therefore, reliance is often placed on fellow workers to advise the supervisor if 

another individual’s work is not up to par. This situation can create challenges in identifying and 

effectively managing or re-training employees whose work does not conform to WMATA’s 

established SOPs, OAPs, and standards. 

Across maintenance departments, many WMATA frontline maintenance personnel noted that 

while supervisors currently do what they can to support on-the-job training and mentoring of 

employees, there are not sufficient resources in place to create a formal program for supervisory 

inspections to observe the performance of maintenance, to look at quality of work in the field, 

and to formally intervene to re-train employees. 

•	 Finding R-33: Inventory “stockouts” have impacted maintenance operations. 

Material control stock out items are reported by Superintendents in Rail Car 

Maintenance, Traction Power and Plant as a serious concern in the performance of 

maintenance activities and ensuring equipment availability, however mitigations 

have not been implemented. 

Finally, FTA’s SMI team found that WMATA’s maintenance activities are being impacted by 

inventory “stockouts” of critical parts. “Stockouts” is a term that means out of stock inventory 

for a specific part or item. When a part is not available to support scheduled or corrective 

maintenance, then this maintenance activity must be deferred or parts must be obtained from 

other sources (i.e., other vehicles removed from service). 

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Material control stock out items are reported by Superintendents in Rail Car Maintenance, 

Traction Power and Plant as a serious concern in the performance of maintenance activities. For 

example, in Rail Car Maintenance, brake pad shortages protracted for over three months and 

forced the cannibalization of brake pads from out of service rail cars and trucks in process for 

rebuild. A review of stock outs for August 2014 and March 2015 (two random points in time) 

disclosed that 170 items in August 2014 and 270 items in March 2015 were unavailable for 

maintenance requirements. Brake hoses, red insulating paint, disc brake assembly, and brake 

calipers were among the stock out items. 

Required	Actions

Safety Directive 15-1 identifies seven required actions to be taken by WMATA to address safety 

deficiencies in system-wide maintenance issues. 

Metrorail Category 4: System-wide Maintenance Issues 

Findings Required Actions (Specified in Safety Directive 15-1) 

Finding R-27 Documented maintenance 

procedures and standard 

operating procedures are 

not implemented as 

required. 

R-4-27-a For all major departments with inspection and maintenance 

responsibilities for critical infrastructure, WMATA must establish and/or 

update a preventive maintenance and inspection testing quality audit 

process to ensure compliance with established maintenance and 

testing practices, and to monitor missed or incomplete preventive 

maintenance activities and/or inspections. 

Finding R-28 Walking track inspection 

resources have been cut in 

half. 

R-4-28-a WMATA must review the workload and inspection territory assigned to 

track inspectors, and leverage non-track inspectors to perform 

watchman duties. 

Finding R-29 All ATC alarms and issues 

must be communicated to 

ATC for investigation, repair 

and analysis. 

R-4-29-a WMATA must ensure that ROCC reports all signal alarms and 

notifications to ATC. 

Finding R-30 WMATA’s program for 

measuring, documenting 

and addressing the potential 

impacts of stray negative 

return current on the 

condition of WMATA’s 

infrastructure is not 

documented in a formal plan 

to ensure coordination 

across departments and 

contractor services. 

R-4-30-a WMATA must develop a plan to document roles and responsibilities, 

activities, and points of coordination regarding its program to measure, 

document and mitigate the impacts of stray negative return current. 

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Metrorail Category 4: System-wide Maintenance Issues 

Findings Required Actions (Specified in Safety Directive 15-1) 

Finding R-31 ATC resource challenges 

potentially impact service 

expansion. 

R-4-31-a WMATA must assess adequacy of Automatic Train Control staffing 

levels resulting from the addition of the Silver Line. 

Finding R-32 WMATA has no formal 

program for reviewing the 

proficiency of maintenance 

field staff. 

R-4-32-a WMATA must ensure that each department within Transit 

Infrastructure and Engineering Services creates a formal program of 

Supervisory inspections to observe maintenance, look at quality of 

work in the field, and formally intervene to evaluate, re-train (if 

necessary), and enhance the professional development of employees. 

Finding R-33 Inventory “stockouts” have 

impacted maintenance 

operations. Material control 

stock out items are reported 

by Superintendents in Rail 

Car Maintenance, Traction 

Power and Plant as a 

serious concern in the 

performance of 

maintenance activities and 

ensuring equipment 

availability, however 

mitigations have not been 

implemented. 

R-4-33-a Each WMATA Department impacted by inventory stockouts must 

develop a recovery or corrective action plan to ensure equipment 

availability and to manage delays. 

5.5 Category R-5: Fire/Life Safety and Emergency Preparedness 

FTA’s SMI team identified two findings regarding WMATA’s fire/life safety and the 

management of the infrastructure conditions that contribute to smoke and fire events. 

Situation

WMATA’s biggest corrective maintenance challenges occur for infrastructure elements with 

shared responsibilities across departments. Based on extensive field reviews, records reviews, 

including work orders and corrective maintenance inspections, interviews and observations, 

FTA’s SMI team determined that, against a general backdrop of attempted conformance with 

maintenance requirements, enhanced coordination is needed across WMATA departments with 

shared responsibility for maintaining critical infrastructure to ensure prioritized response to 

defects and failures. 

•	 Finding R-34: Priority maintenance work for Fire/Life Safety (FLS) systems and 

other critical infrastructure with shared departmental responsibilities for inspection 

and maintenance is not completed as required. 

Shared maintenance responsibilities across departments for critical infrastructure items such as 

traction power cables at expansion joints, fire/life safety systems, the AIM system, elements of 

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the signal and train control system, and passenger communication systems are not always 

understood in the field or acted on in assigning and completing corrective maintenance work 

orders. Specifically for WMATA’s critical fire/life safety systems, FTA’s SMI team identified 

several instances where supporting departments did not complete priority repairs required in the 

tunnel ventilation system in a timely manner. For example, two ventilation fans in WMATA’s 

deepest tunnel location were locked out for over six months waiting for the Power branch to 

complete a repair. Repairs for transfer switches and communication cables also lagged. Updates 

to the AIM system to enhance the visual display to more accurately depict the location of key 

fire/life system have also received lower priority than other maintenance initiatives and 

activities. 

FTA’s SMI team also identified confusion among WMATA maintenance employees regarding 

the definition of key terms and conditions essential to prioritizing reports regarding serious 

fire/life safety malfunctions in traction power, track, signal and train control system, and the 

remote terminal units that support the AIM system visual display. For example, FTA’s team 

found confusion over the definition of an “arcing insulator.” FTA’s SMI team found a variety of 

terms from “sparkling” to “smoking” applied to insulators that diminish the severity of the 

report. “Arcing” insulators must be investigated and replaced immediately; insulators described 

with other terms do not. 

WMATA is developing a “Fire/Life Safety 1000” maintenance procedure, to clarify roles and 

responsibilities, and outline expectations regarding how departments should work together to 

coordinate and prioritize inspection, maintenance and repair of these system components. This 

procedure is being based on the agency’s “ATC 1000” procedure developed in the wake of Fort 

Totten accident to ensure an enhanced focus on the testing and maintenance of track circuits and 

other wayside equipment. 

•	 Finding R-35: WMATA must do more to prevent and manage conditions that cause 

smoke in tunnels. 

Based on review of safety data reported to the FTA NTD, FTA’s SMI team observed that 

WMATA has been experiencing a growing number of fires and smoke events, whether related to 

the changing performance of the traction power system as it manages new electricity demands 

for 8-car trains, changing weather conditions requiring sudden spikes in energy consumption for 

heating or cooling, increased debris on tracks and grime build-up on insulators and other traction 

power system components, or other causes. 

In 2014, WMATA experienced almost twice as many events requiring fire suppression as in 

2013 (29 versus 15). For the first four months of 2015, WMATA has experienced 2 major fire 

events and 10 events requiring suppression, and is on target to exceed last year’s total. 

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Washington Metropolitan Area Transit Authority – Heavy Rail Fires 

Fire Type 2013 2014 2015* 

Major Fires 0 1 2 

Non-major Fires** 15 28 10 

Total 15 29 12 

*Includes January through April 

**Non-major fires are those that do not meet a reporting threshold but require suppression 

Source: National Transit Database, 5/31/2015 

In reviewing this issue, FTA’s SMI team confirmed that while WMATA does have smoke 

detectors at specific locations, currently WMATA does not have the means to determine the 

exact location of a source of smoke in the tunnel network. This lack of on-the-ground 

information regarding the exact location of smoke can complicate both the reporting of and 

response to these events. 

Follow-up interviews with WMATA maintenance personnel demonstrated some confusion 

regarding which department was responsible for specific inspection and maintenance activities 

that will reduce the likelihood of smoke or fire on the WMATA system. For example, TRST 

personnel responsible for maintaining the third rail cover board and third rail supports 

(insulators) revealed considerable confusion regarding the responsibility of inspecting cabling 

around third rail expansion joints. While this cabling is technically the responsibility of POWR, 

some TRST personnel indicated that they inspect these cables and report problems to POWR, 

while other TRST personnel do not. Correspondingly, some POWR personnel interviewed by the 

SMI team were not aware of their responsibility to inspect the condition of these joints, assuming 

this activity was performed by TRST. Also, there was no clear understanding regarding 

responsibility for cleaning older third rail insulators that have accumulated steel dust and grime 

and that can cause smoke conditions. Responsibility for cleaning these insulators, and 

requirements surrounding their maintenance or replacement, are still being defined by 

WMATA’s engineers and maintenance team. 

WMATA discontinued a program to test the insulation resistance of power cables several years 

ago, opting instead for replacement. However, funding ran out for this program, and cable 

replacement has largely stopped. To address this issue, WMATA recently identified specific 

steps that will be taken to inspect the condition of all third rail jumper cables located in tunnel 

sections and provide an “engineering and operations report” on their condition and installation. 

Also, as a result of the January 2015 incident, WMATA has decided to conduct an assessment 

regarding required replacements of high voltage third rail jumper cables with low smoke/low 

halogen cables. WMATA is also installing mechanical protection on third rail jumper cables 

potentially exposed to wear from vibration against other materials. WMATA also committed to 

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inspect and review ground fault detectors on third rail circuit breakers, and to perform an 

operational analysis to determine whether WMATA can limit current flow through the electrical 

infrastructure by running trains at 45 miles per hour in the system core. WMATA also 

established a schedule of quarterly drills to exercise capabilities to manage emergency events in 

tunnel and on elevated structures. 

Required	Actions

Safety Directive 15-1 identifies seven required actions to be taken by WMATA to address FTA’s 

findings regarding WMATA’s management of fire/life safety issues and concerns. 

Metrorail Category 5: Fire/Life Safety and Emergency Preparedness 

Findings Required Actions (Specified in Safety Directive 15-1) 

Finding R-34 Priority maintenance work 

for Fire/Life Safety (FLS) 

systems and other critical 

infrastructure with shared 

departmental 

responsibilities for 

inspection and 

maintenance is not 

completed as required. 

R-5-34-a WMATA must complete its “Fire/Life Safety 1000” maintenance 

procedure, to clarify roles and responsibilities, and outline 

expectations regarding how departments should work together to 

coordinate inspection, maintenance and repair of these system 

components. 

Finding R-35 WMATA must do more to 

prevent and manage 

conditions that cause 

smoke in tunnels. 

R-5-35-a WMATA must establish clear definitions for infrastructure conditions 

requiring immediate or emergency action, such as “arcing insulator.” 

R-5-35-b WMATA must address third rail insulator cleaning and replacement 

requirements and third rail jumper cable inspection and replacement 

requirements as part of the “FLS 1000” procedure, or in separate but 

referenced procedures. 

R-5-35-c WMATA must improve its ability to detect the location of smoke in its 

tunnel network. 

R-5-35-d WMATA must resume its program for cable insulation resistance 

testing for its power cables. Insulation resistance testing should be 

performed on power cables every 10 years. 

R-5-35-e WMATA must replace all defective power cables that have been 

identified by traction power inspectors and maintainers. 

R-5-35-f WMATA must set a schedule of drills to assess the effectiveness of 

WMATA’s response to smoke in tunnel and station conditions. 

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5.6	 Category R-6: Condition and Performance of Tunnel Ventilation 

System 

FTA’s SMI team identified three findings related to the condition and performance of 

WMATA’s tunnel ventilation system. 

Situation

WMATA’s tunnel ventilation system is used to retain or remove heat generated by trains and to 

support air quality in the tunnels and underground stations. Tunnel fans and fan shafts/vent 

shafts are also used to remove smoke from the tunnels in the event of fire or other conditions. 

Tunnel fans are reversible and are controlled by the ROCC; they also can be operated locally 

from the control panel near the fan. The fans and dampers work together to evacuate smoke. 

Vent shaft dampers close to seal the vent shaft and allow smoke or fumes to be pulled to the fan 

shaft and ejected outside. The static condition of the fans is OFF. They are only designed to 

move air in emergencies or during work efforts. 

WMATA has 85 total fan shaft/vent shaft sites, including 82 sites that house fans, and three fan 

control rooms for fans with wayside locations. With the Silver Line extension, WMATA has just 

under 400 total fans. Older fans have a rated capacity of 50,000 cubic feet per minute (air flow). 

Newer fans have significantly higher rated capacities. 

The majority of WMATA’s fan shafts have units that contain three to six fans with 5-foot blades 

that operate in series and are controlled pneumatically. In ten shafts, WMATA has the newer 

programmable logic control (PLC) boxes to test and operate the fans locally. The Silver Line is 

equipped with two sets of brand-new jet fans. 

At the fan shaft, when conducting inspections or repairs, WMATA’s PLNT mechanics have 

access to a selector switch on the fan controls, which gives them the following options: 

•	 Remote (this is the default setting that gives ROCC the ability to operate remotely, 

coming out of this position triggers a remote control abnormal alarm at the ROCC), 

•	 Off, 

•	 Local Supply, and 

•	 Local Exhaust. 

At ROCC, the controllers have access to a fan menu, which gives them the following options: 

•	 Auto Exhaust – In this setting, the mode of operation is set to exhaust and the fans will 

operate automatically in exhaust mode only as follows: 

o	 When the tunnel temperature reaches 95 degrees, one fan will come on line. 

o	 If the tunnel temperature continues to climb and reaches 96 degrees, a second fan 

comes on line. The process will continue for each additional increase of 1 degree 

if there are more than 2 fans in that location. 

•	 Auto Supply – In this setting, the mode of operation is set to supply and the fans will 

operate as described above, except in supply mode. 

•	 Emergency On Exhaust – This option commands all fans on in exhaust mode (fans will 

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come on line sequentially after programmed timed delay between each fan). 

•	 Emergency On Supply – This option commands all fans on in supply mode (fans will 

come on line sequentially after programmed timed delay between each fan). 

•	 Fan Automatic On – This command places the fans in a state to run automatically as 

defined above. The mode of operation (exhaust or supply) will be in the same direction of 

the last commanded mode setting. 

•	 Fan Emergency On – This option commands all fans on. The fans will operate in the 

same direction of the last commanded mode setting (exhaust or supply). 

•	 Fan Emergency Off – This option commands all fans off. 

The ventilation system display on the AIM system conveys very basic data: users at the ROCC 

can select a fan to view its basic condition (whether it is under local or remote control, whether it 

is in supply or exhaust, whether the system is behaving abnormally). RTCs can select fans to run 

in automatic exhaust or supply or emergency exhaust or supply (overrides tunnel conditions and 

forces fans to run). 

RTCs have very little diagnostic information regarding fans or their performance once activated. 

RTCs interface with the fans mostly as requested during scheduled preventive maintenance 

inspections. RTC interaction is limited to remote control of the fans in both directions, and 

confirmation to maintenance employees that the AIM system displays the appropriate fan status. 

Due to the age of the fans and control boxes, and the limitations of the AIM system, RTCs 

cannot confirm the status of the fans as available for remote operation, though alarms are 

indicated initially whenever a fan is taken out of remote. 

On the AIM system, the alphanumeric codes used to indicate both stations and fan shafts do not 

correspond perfectly: for example, FA07 (fan shaft 07) does not correlate to A07 (station A07), 

but rather to A05 (station A05). The different alphanumeric schemes can cause confusion for 

RTCs and mechanics conducting preventive maintenance checks with ROCC and during 

incidents and emergencies. 

As discussed in the Fire/Life Safety section of this report, different WMATA Departments have 

responsibility for the inspection and maintenance of the various components that comprise 

WMATA’s many emergency systems, including the tunnel ventilation system. Specifically for 

the tunnel ventilation system: 

•	 PLNT is responsible for the mechanical infrastructure of the tunnel fan system and the 

associated electronic and mechanical controls. PLNT handles the low voltage (120 volt) 

components, including all mechanical and pneumatic elements of the system. PLNT has 

no licensed electricians, or communications technicians, and relies on other departments 

for these capabilities. PLNT identifies its responsibilities as largely located in the fan 

shaft from the Data Transmission System (DTS) box back to the fan. PLNT has the 

greatest responsibility for the tunnel ventilation system. PLNT’s Equipment (EQMT) 

group performs the Tunnel Ventilation inspections and maintenance activities. Each fan 

shaft receives monthly maintenance inspections. 

•	 ATC technicians maintain the link from the DTS box to the ROCC and the AIM system, 

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which includes the remote terminal units (RTUs) located in the train control rooms. 

•	 The ROCC has the ability to remotely operate the tunnel fans, and is responsible for 

processing alarms and addressing any issues by notifying the appropriate personnel. 

•	 The ROCC also communicates with PLNT during monthly inspections to confirm, to the 

extent possible, the functioning of the fans and alarms, though often, due to the volume of 

activity experienced at ROCC, these tests may not be performed in a timely manner for 

PLNT personnel located remotely at the fan site. FTA’s SMI team noted that the 

alphanumeric codes used to indicate both stations and shafts appear to cause some 

confusion between the ROCC and PLNT; FA07 (fan shaft 07) does not correlate to A07 

(station A07), but rather to A05. 

•	 POWR inspects and maintains the motor control center and transfer switches, and also 

maintains the automatic voltage regulator. POWR is responsible for all high-voltage 

elements of the tunnel ventilation system (460/480 AC), including emergency trips and 

circuit breakers. 

•	 Emergency personnel have the ability to control the fans locally during an emergency. 

They coordinate with ROCC to gain access to the system. 

Electronic communications between the fan system and ROCC travel in both directions, with the 

ROCC able to send commands to the fan and the fan relaying a signal received response as well 

as some basic information as to fan system status. The ROCC can send five basic commands: 1) 

Emergency off; 2) Emergency on; 3) Remote control auto; 4) Supply; and 5) Exhaust. In 

response, the fan system can send 10 responses to the ROCC: 1) Accept emergency off; 2) 

Accept emergency on; 3) Accept remote control auto; 4) Accept supply; 5) Accept exhaust; 6) 

Damper abnormal alarm; 7) Operation abnormal alarm; 8) Low (45 degree) tunnel temperature 

alarm; 9) High (95 degree) tunnel temperature alarm; and 10) Remote control abnormal alarm. 

If the ROCC initiates emergency fan operations, vent shaft dampers close and fan shaft bypass 

dampers close. The fan dampers open, and the fans run as commanded (exhaust or intake; default 

is exhaust and unless commanded otherwise, fans run in exhaust). After a 20 second delay 

between the signal and the first fan energizing, the first fan energizes, with each subsequent fan 

energizes an additional 10 seconds after the last. Fans will continue running until they receive an 

“off” command. If commanded to run in reverse order, fans will reverse the above process after a 

20 second delay. These delays allow the fans to get up to speed before adding another load to the 

system. 

“Remote control abnormal” alarms are triggered at the ROCC if there is a loss of air pressure 

(vent shaft and bypass dampers return to their closed position and fan dampers open) OR during 

loss of electrical power events. The motors have a tolerance of approximately +/- 10% of 460V. 

Transfer switches will trip the source from normal to emergency when the power drops too low. 

The unit being turned to local control or off by a maintenance employee performing work can 

also trigger these alarms. 

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“Operation abnormal” alarms are triggered if fans fail to rotate or rotate in the wrong direction as 

indicated by air flow sensors located on either side of the fan blades. “Damper abnormal” alarms 

are triggered when fan dampers fail to open as monitored by a limit switch on the fan. There are 

no vent shaft damper alerts. Each of these alarms requires a visit by a mechanic to identify the 

issue. 

On February 11, 2015, the NTSB issued Urgent Safety Recommendation R-15-8 to WMATA: 

“Assess your subway tunnel ventilation system to verify the state of good repair and 

compliance with industry best practices and standards, such as those outlined in the 

National Fire Protection Association (NFPA) 130, Standard for Fixed Guideway Transit 

and Passenger Rail Systems.” 

In the weeks prior to FTA’s SMI, as requested by the NTSB, WMATA completed an extensive 

inspection of all ventilation fans and shafts. PLNT developed the schedule, which was provided 

to WMATA’s Safety department and TOC, in advance, and a member of the Safety or Quality 

department accompanied PLNT staff on most of the inspections (some of the observers signed 

below the mechanic’s signature line). TOC also observed inspections. The complete set of 

inspection checklists was provided to FTA’s SMI team. 

Using the checklists as a reference, FTA’s SMI team split into two groups to conduct field 

observations of PLNT preventive maintenance inspections on WMATA’s tunnel ventilation 

system. The ROCC was extremely responsive to the PLNT crews being observed by FTA’s SMI 

team. According to PLNT personnel, the time to perform the PMIs was reduced dramatically as 

a result of this heightened attention from ROCC. 

The table on the next page lists the defects identified by WMATA from their inspection of all fan 

shafts and fans. At the time of FTA’s SMI, work was underway to address and resolve each item. 

FTA’s on-site inspections confirmed the conditions in location FA-13 on the Red Line, where 

fans number 5 and 6 have been out of service and locked out since September 11, 2014, due to a 

low power issue. 

FTA also confirmed an existing Work Order at this location pertaining to the Transfer Switch. 

When tested, the transfer switch did not work. This location is the deepest fan shaft on the 

WMATA system, and the most challenging to access. FTA’s inspection also confirmed the 

condition and performance of fans in five other shafts, and the conformance of their condition to 

the inspection results documented on the corresponding forms. 

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WMATA Fan Shaft Discrepancy Work List 

as of 3/18/2015 

Location # of Fans DEPT Reported Item Corrective Action ECD 

FA-11 3 PLNT/PWR 

Fan #5 did not start (No power 

from MCC Panel to disconnect 

switch) 

2 Fans operational 

Circuit breaker has been replaced, but motor was found to be defective. 

New motor ordered (8-12 week lead time). Work order #11586296 

Fan shaft at 66% operational capacity. 

5/27/2015 

FA-13 6 PWR 

2 Fans locked out due to Low 

voltage condition in the fan shaft. 

4 fans operational 

SMNT/PLNT/CENI performed site visit 2/23/2015 to verify operation. 

Contractor being scheduled to retrofit voltage regulator. 

Two fans will be kept out of service to prevent entire panel from 

tripping out. 

Fan shaft at 66% operational capacity. 

4/19/2015 

FA-14 4 PWR 

1 fan locked out due to low voltage 

condition at in the fan shaft. 

3 fans operational. 

SMNT/PLNT/CENI performing site visit 2/23/2015 to verify operation. 

Contractor is being scheduled to retrofit voltage regulator. 

One fan will be locked out of service to prevent entire panel from 

tripping out. 

Fan shaft at 75% operational capacity. 

4/19/2015 

FE-9 3 PWR 

Transfer switch stuck. Knife switch 

broken. 

All fans are operational. 

SMNT has ordered a new transfer switch. 

Transfer switch is locked in normal mode. 

Fan shaft at 100% operational capacity. 

4/15/2015 

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WMATA Fan Shaft Discrepancy Work List 

as of 3/18/2015 

Location # of Fans DEPT Reported Item Corrective Action ECD 

FL-1 4 PLNT/PWR/ 

CENI 

This site has a low voltage 

problem. Two of four fans trip 

intermittently 

3 fans operational. 

PLNT ordered new motor starters: 

PLNT will install new PLC Control Cabinet: 

Contractor will be scheduled to retrofit regulator: 

One fan will be locked out of service to prevent entire panel from 

tripping. 

Fan shaft at 75% operational capacity. 

3/20/2015 

Completed 

3/11/2015 

4/23/2015 

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•	 Finding R-36: Demonstration of compliance with required inspection and 

maintenance procedures must be improved. 

While FTA’s SMI team generally found that the condition and performance of fans matched the 

status indicated on the inspection reports, FTA’s SMI team also observed an extreme 

accumulation of dust and grime on the fan faceplates and the pneumatic control boxes. 

Interviews with PLNT personnel also highlighted the low priority assigned in ROCC to fan 

ventilation tests. RTCs may keep PLNT personnel waiting for hours before confirming 

indications or remotely turning on fans. Accessing the fan locations can require carrying tools 

and equipment down as many 20 flights of stairs into dark and confined spaces. Dust is a 

significant concern for workers, and many are now wearing optional respiratory protection 

provided by WMATA. 

Ventilation system inspections are documented on paper-based forms that must be entered into 

WMATA’s maintenance information management system by supervisors. In 2014, PLNT 

personnel performed over 37,000 preventive maintenance inspections and completed over 17,000 

corrective maintenance work tickets annually (not just for tunnel ventilation but also for drainage 

pumping stations and a range of general plumbing, carpentry and maintenance activities). At the 

time of FTA’s SMI, all PLNT field activity was documented on paper forms that then had to be 

inputted into the WMATA MMIS by PLNT Supervisors. 

For preventative maintenance performed on the tunnel ventilation system, as with other PLNT 

field activities, the process of transitioning the paper reports to the MMIS requires two to three 

weeks, potentially delaying work orders and the review of critical data or information regarding 

the condition and performance of the fans. This process also keeps supervisors at their desks 

entering paper-based reports into the MMIS and limits their time to conduct independent audits 

and follow-ups in the field to assess the condition of fans and quality of inspections. 

Given these challenges, and critical importance of the tunnel ventilation system in the event of an 

emergency, FTA’s SMI team determined that PLNT managers currently do not have strong 

enough assurances regarding the performance or quality of monthly inspections. FTA’s team 

also finds POWR and COMM, and the ROCC, have a tremendous amount of influence in the 

inspection, maintenance, testing and performance of this system. WMATA has recognized this 

issue, and is coordinating across departments to establish a quality audit process for the tunnel 

ventilation system as part of the agency’s new Fire Life Safety 1000 inspection, testing and 

maintenance procedure. 

•	 Finding R-37: Newer technology will enhance the performance of inspections and 

their quality. 

The tunnel ventilation systems report through the DTS box to the RTUs, which are located 

within the train control rooms and report back into the AIM system. RTU's handle multiple 

inputs. If an input is down it may not be detected until the next monthly inspection. If the RTU 

input is down the AIM system display would not know unless the RTC attempts to exercise the 

fan site. 

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For the fans with PLC control boxes and for the Silver Line jet fans, PLNT can confirm the 

“absence of alarms” and ensure that all settings and communication from the fans to the DTS 

box are correct; for the pneumatic fans, PLNT can only confirm three of the 10 possible alarm 

settings that a fan can send to a DTS box as part of monthly maintenance. Since these alarm 

settings are designed to fail-safe, and should send a signal to ROCC upon their failure, 

maintenance and performance of signal capability was not initially considered in the 

maintenance program for these fans. 

•	 Finding R-38: WMATA’s existing tunnel ventilation system was designed and 

installed before modern fire/life safety standards were issued for the rail transit 

environment, however, with growing passenger loads and eight-car trains, WMATA 

must look for opportunities to improve ventilation performance and capacity. 

Most of WMATA’s pneumatically controlled fans are 30-40 years old and do not meet all 

requirements specified in NFPA 130 Standard for Fixed Guideway Transit and Passenger Rail 

Systems. In fact, many of WMATA’s fans were designed and installed before NFPA 130’s 

initial version was even issued in 1983. While these older fans do not meet modern air 

movement capacity standards, all of them are reversible, and can be controlled by the ROCC and 

also operated locally from the control panel. 

Given the challenges in terms of available space and ducting in established tunnels and stations, 

WMATA engineers report that while replacing these fans with more modern equipment would 

improve capacity, currently available equipment, which would fit the existing dimensions of the 

shafts, would not bring the system into compliance with NFPA 130. 

For the last decade or so, all WMATA design criteria require NFPA 130 compliance. For 

example, the Silver Line and associated new construction are compliant with NFPA 130 

provisions. However, WMATA has made minimal changes to its ventilation system over time to 

address growing passenger loads and eight-car trains. 

WMATA has reviewed other engineering and modification options to increase capacity, 

however, and while modifications can be made for some improvement in cubic feet of air flow 

per minute, drilling and tunneling for the space and new equipment required to bring the existing 

system into full compliance with modern NFPA 130 standards would likely cost billions of 

dollars. 

Required	Actions

Safety Directive 15-1 identifies four required actions to be taken by WMATA to address safety 

deficiencies related to FTA’s findings on the inspection, maintenance and performance of 

WMATA’s tunnel ventilation system. 

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Metrorail Category 6: Condition and Performance of Tunnel Ventilation System 

Findings Required Actions (Specified in Safety Directive 15-1) 

Finding R-36 Documentation and 

scheduling of tunnel 

ventilation system 

inspections must be 

improved to ensure 

compliance with required 

procedures. 

R-6-36-a WMATA must establish a ventilation system testing quality audit 

process to ensure compliance with established maintenance and 

testing practices. 

R-6-36-b WMATA must automate inspection and maintenance record keeping 

for tunnel ventilation systems, drainage pumping stations, and other 

critical systems managed by the Office of Plant Maintenance. 

Finding R-37 Newer technology will 

enhance the performance 

of inspections and their 

quality. 

R-6-37-a WMATA must complete replacement of the pneumatic control boxes 

for ventilation fans with Programmable Logic Control systems within 

the next five years. 

Finding R-38 WMATA’s existing tunnel 

ventilation system was 

designed and installed 

before modern fire/life 

safety standards were 

issued for the rail transit 

environment, however, 

with growing passenger 

loads and eight-car trains, 

WMATA must look for 

opportunities to improve 

ventilation performance 

and capacity. 

R-6-38-a WMATA must conduct an engineering assessment to identify ways in 

which to improve the performance and capacity of the tunnel 

ventilation system. 

5.7 Category R-7: Performance of Information Management Technology 

FTA’s SMI team identified four findings related to performance of information management 

technology used by WMATA’s operating and maintenance departments. 

Situation

As a result of interviews and records review with several operating and maintenance 

departments, FTA’s SMI team found that documentation of initial and refresher training, 

certifications, professional licenses, and re-certifications is generally very poor. Over the last two 

years, in an effort to streamline and consolidate WMATA’s recordkeeping systems, the agency’s 

training and certification records were incorporated into an integrated Enterprise Learning 

Management (ELM) system. 

•	 Finding R-39: Difficulties with WMATA’s ELM have forced departments to use 

work-arounds resulting in poor documentation of initial and refresher training, 

certifications, professional licenses and re-certifications. 

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Although it appears that WMATA intended this transition to the ELM system to streamline the 

recordkeeping processes and procedures of all WMATA departments and to reduce the burden 

on individual entities and personnel, the system’s ability to serve as an effective system of 

training records management is questionable at the present time. Many WMATA managers find 

the ELM system to be complicated, inflexible or difficult to use to track training. As a result, 

many departments at WMATA have developed work-arounds and tracking tables in Microsoft 

Excel, Access or Word. As discussed in earlier sections of this report, regarding confusion over 

training records for RWP refresher and requalification training, FTA’s SMI team found that, due 

to challenges in using the ELM system, WMATA’s managers do not have real-time access to 

their training records, nor do they have full confidence in the training records tracking system. 

•	 Finding R-40: WMATA’s MMIS, in its current configuration, is cumbersome and 

challenging to use for many WMATA maintenance employees. 

FTA’s SMI team also found that WMATA’s use of its MMIS could be improved significantly to 

prioritize safety-critical maintenance work. FTA’s SMI team identified numerous instances 

where WMATA’s MMIS was not used as designed due either to poor data entry, lack of training, 

or lack of maintenance manager access to specific fields or information. Reports on safety 

critical maintenance activities were not readily available. 

To address the lack of training and wide-spread skill in use of the MMIS, most WMATA 

maintenance departments have subject matter experts available to screen data and generate 

reports. Such screening is necessary because issues with data entry and work order creation must 

be managed manually to ensure accurate reports. In many cases, reports or data from the MMIS 

are exported to other programs for trending and analysis. Therefore, due to both the complexity 

of the maintenance management information system, and the generally poor quality of data 

entry, WMATA maintenance managers and supervisors cannot generate reports directly to help 

them manage their employees and activities, but must rely on specialists within their departments 

or within specific quality and reliability functions. 

During the onsite interviews, FTA’s SMI team requested MMIS reports to verify maintenance 

activities. In one example, a number of the reports were not readily available to CMNT and it 

was necessary for CMNT to contact support groups to acquire the reports. For example, during 

discussions regarding material shortages it was noted that on occasion WMATA would lose as 

many as 66 collector shoes in one day due third rail alignment issues. When asked for a report to 

show the total number of collector shoes lost in the previous year, CMNT was not able to quickly 

produce the report. Such reports should be easily accessible to enable budgeting and establishing 

reorder quantities to prevent material stockouts as well as to identify causal issues to implement 

mitigations. 

•	 Finding R-41: WMATA’s IT Department lacks necessary authority to ensure that 

all WMATA departments use IT applications in the same manner to ensure data 

sharing, coordination of training, and conduct of audits in a consistent manner. 

FTA’s SMI team also determined that information technology and computer-based applications 

established at WMATA to improve efficiency, transparency and effectiveness of operations and 

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maintenance activities are not meeting expectations. WMATA’s Department of Information 

Technology faces numerous challenges in working toward an enterprise-based approach where 

all WMATA departments use the same IT applications in the same manner, and can share data, 

coordinate training, and conduct audits and reviews in a consistent manner. 

Through the course of the SMI, FTA’s team learned that WMATA’s IT Department cannot 

dictate how the other WMATA Departments use IT products, so while the IT Department can 

identify short-comings in coordination, training, and data quality, it does not have the authority 

to mandate how IT projects and systems are managed by the other departments. 

While every IT project is managed following a fairly consistent framework, with a project 

manager assigned, identified internal and external customers, and an engagement strategy that 

includes a charter with base requirements, a budget, assumptions, a list of interdisciplinary team 

members, and an Executive Steering Committee, the decisions of the individual departments 

ultimately drive the technology deployment. Representatives from IT reported to FTA that they 

strongly opposed the timing of the decisions made to upgrade both the agency’s ELM and 

maintenance information management system, but ultimately did not control the approach or 

process. 

IT also faces limitations in contracts regarding training and manuals. For example, IT has a 

restricted training budget for the AIM system, and WMATA’s MMIS and ELM systems. IT’s 

contracts typically include initial support for train-the-trainer with WMATA personnel, but 

follow-on training must be coordinated, arranged and funded separately. For example, training 

for upgrades to the AIM system (like the recent Silver Line upgrade), which is owned by 

Rockwell Collins, was provided to WMATA under contract for both the IT organization and the 

Rail Operations Quality Training Department. Additional training or re-training in the AIM 

system technology would have to be scheduled independently and would require additional 

funding. 

•	 Finding R-42: Proactive safety analysis of information provided by Operating and 

Maintenance departments is not routinely conducted. 

Finally, in reviewing the performance of WMATA’s information management technology 

system, FTA’s SMI also reviewed the Safety Measurement System application developed by 

WMATA’s Safety and Environment Management Department. FTA finds that while SAFE 

continues to expand and enhance its program activities and to grow its departmental capabilities, 

more can be done to support WMATA’s Operating and Maintenance Departments in identifying 

and managing safety issues and concerns. 

Throughout the conduct of the SMI, FTA’s team found additional opportunities for SAFE to 

conduct more proactive analysis of information identified by operating and maintenance 

departments; to provide more active support for efficiency and proficiency testing of operational 

and maintenance personnel, and to conduct more thorough accident and incident investigations. 

Further, SAFE may be better equipped than other departments to incorporate WMATA’s RWP 

training program into its other suite of safety training activities, and to have its Trainers and 

SAFE Officers enforce RWP refresher and re-certification requirements. 

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Required	Actions

Safety Directive 15-1 identifies eight required actions to be taken by WMATA to address safety 

deficiencies related to the performance of information technology on the Metrorail system. 

Metrorail Category 7: Performance of Information Management Technology 

Findings Required Actions (Specified in Safety Directive 15-1) 

Finding R-39 Difficulties with WMATA’s 

ELM have forced 

departments to use workarounds resulting in poor 

documentation of initial and 

refresher training, 

certifications, professional 

licenses and recertifications. 

R-7-39-a WMATA must evaluate the existing Enterprise Learning 

Management recordkeeping system and take corrective action, as 

necessary, to ensure accurate training, re-certification, and 

professional certification records are created, maintained, and readily 

accessible to appropriate managers and employees. 

Finding R-40 WMATA’s MMIS, in its 

current configuration, is 

cumbersome and 

challenging to use for many 

WMATA maintenance 

employees. 

R-7-40-a WMATA must develop a training strategy for improving the 

capabilities of employees to enter, analyze and assess information 

into the agency’s Maintenance Management Information System. 

R-7-40-b WMATA must establish a data reliability working group focused on 

maintenance information. 

R-7-40-c The Information Technology Department must coordinate with the 

Technical Training Department to ensure the availability of additional 

training on the use of WMATA’s Maintenance Management 

Information System for WMATA’s maintenance departments. 

Finding R-41 WMATA’s IT Department 

lacks necessary authority to 

ensure that all WMATA 

departments use IT 

applications in the same 

manner to ensure data 

sharing, coordination of 

training, and conduct of 

audits in a consistent 

manner. 

R-7-41-a WMATA must assess data accessibility and coordination needed to 

support safety functions throughout the agency including the 

operations and maintenance departments. 

R-7-41-b The Information Technology Department must coordinate with Rail 

Operations Quality Training to ensure the availability of additional 

training for the Rail Operations Control Center staff on the Advanced 

Information Management system. 

Finding R-42 Proactive safety analysis of 

information provided by 

Operating and Maintenance 

departments is not routinely 

conducted. This negatively 

impacts ability of WMATA to 

provide more support for 

proficiency testing, conduct 

R-7-42-a WMATA operating and maintenance departments must work 

together to develop a strategy to more actively analyze, review, and 

assess rail operations and maintenance data from a safety 

perspective. 

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Metrorail Category 7: Performance of Information Management Technology 

Findings Required Actions (Specified in Safety Directive 15-1) 

more in-depth safety 

studies, reviews and 

accident/incident 

investigations. 

R-7-42-b WMATA must work with the Tri-State Oversight Committee and FTA 

to establish and pilot an enhanced investigation process for rail 

transit accidents, incidents and safety studies that identify systemic 

root causes and deficiencies. 

5.8	 Category R-8: Outstanding Items from Previous FTA Audits and 

Reviews 

As part of the SMI, FTA’s SMI team review WMATA’s progress in addressing critical upgrades 

and repairs to its train control system identified as a result of the NTSB investigation into the 

June 22, 2009 Fort Totten collision. FTA’s SMI team also followed up with WMATA on the 

open item (Recommendation #2) from FTA’s 2012 Safety and Maintenance Audit. This item 

relates to how the agency has managed the safety and engineering concerns associated with 

changes to its track installation and inspection program for continuous welded rail (CWR). 

Situation

•	 Finding R-43: Corrective Action Plans from the 2009 Fort Totten collision remain 

open, including 38 items from the System Implementation Gap Analysis Report 

(SIGAR), which have not yet been addressed. 

After the June 22, 2009 train collision near Fort Totten station, the NTSB made the following 

recommendations to WMATA (dated July 27, 2010): 

•	 R-10-12: Conduct a comprehensive safety analysis of the Metrorail automatic train 

control system to evaluate all foreseeable failures of this system that could result in a loss 

of train separation, and work with your train control equipment manufacturers to address 

in that analysis all potential failure modes that could cause a loss of train detection, 

including parasitic oscillation, cable faults and placement, and corrugated rail. 

•	 R-10-13: Based on the findings of the safety analysis recommended in R-10-12, 

incorporate the design, operational, and maintenance controls necessary to address 

potential failures in the automatic train control system. 

WMATA contracted an independent consultant to perform a safety analysis of the automatic 

train control system to address the NTSB recommendations. This independent review was 

initiated in 2010 and all analysis has since been concluded and presented to the NTSB, who 

closed R-10-12 and R-10-13 on June 25, 2014. 

The analysis resulted in a closeout plan, with all identified items to be tracked and closed in 

WMATA’s Hazard Log and in the System Implementation Gap Analysis Report (SIGAR). 

Based on its review of WMATA’s activity to complete corrective action plans developed to 

address needed improvements identified in this independent review of the signal and train 

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control system, FTA found that WMATA’s ATC unit has fallen behind in keeping its schedule. 

While WMATA has closed out most signal-related NTSB recommendations from the 2009 Fort 

Totten collision, there are still 38 open items from the SIGAR that must be addressed. These are 

important items that will ensure the long-term safe performance of the signal and train control 

system. 

Further, WMATA’s program for replacement of the Alstom Gen II track circuit, which was 

susceptible to parasitic oscillations, is roughly 80 percent complete; however the program is 

more costly than originally anticipated, and the higher cost is adversely impacting other areas of 

the ATC budget. It is unclear if there are sufficient resources and staff available to complete this 

work by the proposed 2017 deadline. 

Finally, FTA’s SMI team found that the replacement of 53 cables with low insulation resistance 

readings has been deferred due to lack of funding. Field personnel reported that budgetary cuts 

and staffing limitations may also impact their ability to continue performing insulation resistance 

testing as required. WMATA’s executive leadership team assured FTA that insulation resistance 

testing for ATC cables would not be discontinued under any circumstance. 

•	 Finding R-44: CWR installation and maintenance program changes have not been 

sufficiently evaluated. 

Sine 2012, FTA has been following up with WMATA regarding the agency’s approach to 

installing roughly 12 miles of new track each year and to managing other repairs and track 

upgrades. At issue is FTA’s concern regarding WMATA’s process for managing continuous 

welded rail (CWR). 

Rail lengths welded together that exceed 400 feet are considered CWR. Rail installed as CWR 

remains CWR, regardless of whether a joint or plug is installed into the rail at a later time. 

Temperature variations affect rail length. Rail expands (lengthens) when heated and contracts 

(shortens) when cooled. Rail neutral temperature is the temperature at which rail is neither in 

tension nor compression. 

Designated rail laying temperatures have been established to provide specific desired rail neutral 

temperatures to prevent track buckling. When laying or adjusting CWR, the desired rail neutral 

temperature is determined based on the geographic location of the agency, the temperature 

variations, and other factors. The difference between the designated rail laying temperature and 

the actual rail temperature taken at the time of installation is called the temperature differential. 

CWR laying and adjusting procedures have been established to compensate for this temperature 

differential 

While FTA has not issued standards for CWR installation, the Federal Railroad Administration 

(FRA) has specified requirements for freight and passenger railroads, including Amtrak and 

CSX, which run alongside WMATA tracks in specific locations, and are subject to the same 

temperatures and weather conditions. 

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FRA, in regulation 49 CFR 213.119, requires each railroad under its jurisdiction that uses CWR 

to develop a CWR Installation, Adjustment, Maintenance and Inspection Plan that includes destressing programs. For installation, FRA requires each railroad to: 

•	 Refer to its established reference tables to identify the designated rail laying temperature 

in its area. 

•	 Take the rail temperature and calculate the expansion required before making 

adjustments. 

•	 Record the rail laying temperature, location and date on approved forms. These records 

may be retained in an electronic format per 213.241. 

•	 While rail does not need to be adjusted when the actual rail temperature exceeds the 

designated rail laying temperature, railroads must use rail heaters or rail expanders to 

adjust the rail to the correct length when the actual rail temperature is less than the 

designated rail laying temperature. 

While WMATA originally had a rail de-stressing program, over the last decade or so, this 

program has largely been eliminated in favor of a heat counter-measures program to closely 

monitor the temperature of the track, and to institute speed restrictions under certain conditions 

in an effort to prevent heat kinks or track buckles, such as occurred during WMATA’s July 6, 

2012 derailment near West Hyattsville. FTA also determined that WMATA experienced two 

heat-related track buckles in June 2014, both of which were identified before passenger trains 

were affected. 

Upon review of WMATA’s existing procedures, FTA’s SMI team finds that WMATA’s current 

“Track Maintenance & Inspection Manual” Revision 6 approved on March 16, 2015, is a 

comprehensive manual covering all necessary aspects of Track Inspection and Maintenance with 

the following exception: 

•	 This revision primarily included WMATA’s previous “Heat Countermeasures Program” 

with a version of a de-stressing program included but not yet implemented. 

•	 This version is significantly reduced from earlier materials submitted to FTA, including a 

modified temperature range and the lack of fully documented calculations and 

accountability required on forms. 

WMATA uses the Vertical Rail Stiffness Equipment (VERSE)4 system for its heat countermeasures program. VERSE is a non-destructive method of measuring the Stress Free 

Temperature (SFT) of CWR using Hooke’s Law (extension is directly proportional to the load) 

to calculate SFT. VERSE requires lifting the rail and logging the load and displacement at 

regular increments throughout the lifting cycle. The outputs from this process are routed via a 

dedicated signal condition system to a hand held computer. Along with some other data such as 

ambient rail temperature, rail profile and height of the rail, the handheld software produces the 

SFT result. The height of the rail is included to take account of rail wear/grinding, which will 

naturally affect the stiffness of the rail. 

4 VERSE is a non-destructive method of measuring the Stress Free Temperature (SFT) of CWR.

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WMATA has faced some budgetary limitations in implementing the VERSE program and fully 

training and staffing crews to conduct the testing. WMATA currently expects to have the 

program fully implemented and staffed by the end of 2015. 

The VERSE program is an industry-leading practice for monitoring the condition of CWR, 

however, it is not, in and of itself, designed to be a substitution for a CWR de-stressing program. 

In response to FTA’s findings from 2012, WMATA has worked to establish a limited rail destressing program. However, as a result of the 2015 SMI, including interviews and further 

review of WMATA’s Track Maintenance & Inspection Manual” Revision 6, FTA finds that 

WMATA’s new procedure for establishing the preferred rail laying temperature must be 

reviewed to ensure that the likelihood of rail buckles is decreased. 

WMATA’s proposed “preferred rail laying” temperature range of +10 to -19 degrees F below the 

preferred rail laying temperature of 95 degrees F far exceeds the original measures WMATA 

previously provided to FTA (+10 to -10 degrees F below), which more closely reflect industry 

standards and FRA tables. 

Using WMATA’s new proposed temperature range, with the rail de-stressed to 76 degrees (95 

degrees F minus 19 degrees), the buckle zone is reached when the rail temperature reaches 126 

degrees F. (The buckle zone is 50 to 70 degrees F above the preferred rail laying temperature.) In 

this situation, on a sunny afternoon, the ambient temperature may only have to reach 86 degrees 

F before conditions could potentially trigger a track buckle. 

Based on interviews with a wide range of representatives from the Track, Track Engineering and 

Quality Departments, many WMATA personnel voiced concern to FTA’s SMI team members 

regarding this new procedure and the proposed temperature range. Given the potential 

implications for WMATA of a more rigorous de-stressing program (slowing down the pace of 

new CWR installation and requiring additional de-stressing methods and procedures and more 

track time), FTA’s SMI team finds that there are considerable disincentives associated with rail 

de-stressing, and that an entirely independent engineering analysis, reviewed by FTA, should be 

performed to ensure the validity of the preferred rail laying temperature range proposed in 

WMATA’s Track Maintenance & Inspection Manual Revision 6. 

Required	Actions

Safety Directive 15-1 identifies five required actions to be taken by WMATA to resolve the 

outstanding items from FTA’s 2012 Safety and Maintenance Audit. 

Metrorail Category 8: Outstanding Items from Previous FTA Audits and Reviews 

Findings Required Actions (Specified in Safety Directive 15-1) 

Finding R-43 Corrective Action Plans 

from the 2009 Fort Totten 

collision remain open, 

including 38 items from the 

System Implementation 

R-8-43-a WMATA must assess the resources assigned to the Automatic Train 

Control Department to ensure their sufficiency to carry out critical work, 

including completion of the program for replacement of the Alstom Gen 

II track circuits by 2017. 

R-8-43-b WMATA must expedite actions to address Corrective Action Plans from 

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Metrorail Category 8: Outstanding Items from Previous FTA Audits and Reviews 

Findings Required Actions (Specified in Safety Directive 15-1) 

Gap Analysis Report 

(SIGAR), which have not 

yet been addressed. 

2009 Fort Totten collision, including the 38 open items from the System 

Implementation Gap Analysis Report (SIGAR). 

R-8-43-c WMATA must replace ATC cables with low insulation resistance 

readings. 

Finding R-44 CWR installation and 

maintenance program 

changes have not been 

sufficiently evaluated. 

R-8-44-a WMATA must complete required submittals to FTA to close-out 2012 

Safety and Maintenance Audit Recommendation #2 relating to the 

WMATA’s rail de-stressing program. 

R-8-44-b WMATA must conduct an independent engineering assessment 

regarding the Critical Rail Neutral Temperature and Preferred Rail 

Laying Temperature Range established in “Track Maintenance & 

Inspection Manual” Revision 6 approved on March 16, 2015, to ensure 

that the likelihood of rail buckles is decreased. WMATA’s proposed 

range (+10 to -19 degrees below the preferred rail laying temp of 95) is 

9 degrees below WMATA’s original measures and does not conform to 

industry standards and recommended practices. 

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6.0 Metrobus Findings and Required Action 

FTA organizes its discussion regarding the findings and required actions from its SMI at 

WMATA Metrobus into five over-arching categories of safety critical concerns: 

•	 Category B-1: Concern over the Protection of Metrobus Operations Personnel 

•	 Category B-2: Limited Availability of Training for Operations and Maintenance 

Personnel 

•	 Category B-3: Inconsistent Operational Testing and Rules Compliance Checks 

•	 Category B-4: System-wide Maintenance Issues 

•	 Category B-5: Lack of Information Management System Technology 

Within these categories, FTA makes specific findings based on the results of interviews, 

document and records reviews, field observations, and independent inspections, testing and 

measurements. In Safety Directive 15-1, FTA issues required actions that WMATA must take to 

address the findings described in each category of this SMI report. Safety Directory 15-1 also 

establishes required response times, a process for FTA approval of work plans, and the FTA’s 

approach to the monitoring of the implementation WMATA’s work plans. 

6.1 Category B-1: Concern over the Protection of Metrobus Operations 

Personnel 

FTA’s SMI team found that WMATA’s employees generally consider the potential for assaults 

by passengers as the greatest safety issue faced on Metrobus operations. This issue affects both 

bus operators and members of the public if the assaults occur while the bus or wheelchair lift is 

in motion, or while passengers are boarding or alighting the bus vehicle. 

Situation

Since 2012, over 175 assaults have occurred against bus operators on the Metrobus system. 

Assaults, which include instances where bus operators are punched, slapped, spit on, have 

objects thrown at them, or are shoved, pulled or pushed, often occur in response to requests made 

by bus operators for passengers to pay fares. A review of data reported to the FTA NTD 

indicates that as many as 50 percent of bus operator assaults nationwide can be traced back to 

fare disputes or issues regarding the performance of fare media and fare vending machines. 

The potential for bus operator assaults is well known at WMATA, and monitored by the agency; 

however, it is a challenging problem, and with many other demands on resources throughout the 

system, the agency has struggled with establishing a coordinated and cohesive approach. 

•	 Finding B-1: WMATA has not addressed operator assaults (by passengers) at a 

level commensurate with the number of occurrences. 

Assaults on operators have caused worker absence, productivity issues, and increased levels of 

stress for the victim and for coworkers. Even minor incidents can be precursors to more serious 

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violence against operators. The Metro Transit Police Department or MTPD tracks operator 

assaults and prepares a special report, outlining specific areas and routes that have increased 

assault totals. Bus operator assaults at WMATA increased by nearly 37 percent in 2014, and the 

first quarter of 2015 saw 2 only two less assaults than the first quarter of 2014. 

MTPD consistently identifies fare evasion as a leading cause of operator assaults. MTPD tracks 

fare evasions by route, day of the week, and time of day, and also has generated heat maps, 

demonstrating significant problem areas. 

In response, Metrobus initiated “We Care” customer service training for bus operators. While 

this program is focused on methods of engaging customers that will increase the customer 

service commendation rate and reduce the complaint rate, this training also emphasizes the 

reality that most assaults stem from fare evasion arguments. Therefore, this training discourages 

operators from escalating the issue with passengers. Operators are instructed to simply state the 

fare amount. If the passenger does not deposit the fare, operators are to record the fare evasion 

by pressing a set button at their console. 

This approach also applies to the enforcement of other fare media, such as the “DC1” fare cards, 

which allow school children to ride for free only during specific hours, or other limited or special 

benefit fare cards. However, both MTPD officers and bus operators acknowledged that the 

environment created by following this approach, and allowing deferred, partial or non-payment 

of fares, particularly among certain groups, such as high school children riding buses after 8:00 

p.m., creates its own challenges for the bus operator among other passengers. 

During the SMI, observations of bus operations confirmed the results of interviews, highlighting 

frequently malfunctioning fare boxes. When riding and evaluating bus routes, FTA’s SMI team 

members observed operators waving passengers to be seated without paying the fare. Under 

questioning in the field, bus operators demonstrated malfunctions in the fare boxes, including 

getting logged out of the fare box system and being unable to log back in. Operators also 

reported their concerns that consistent fare box malfunctions play a role in operator assaults 

when passengers become accustomed to riding for free and then are asked to pay a fare when the 

fare box becomes operational again. 

In addition to the “We Care” program, Local Safety Committees at Bus Divisions also have 

Operator Assault Safety Awareness Initiatives, and WMATA also is installing retractable “driver 

shields” on about 100 buses each year. Operators will have the option of using these shields to 

provide greater separation from the public. 

Metrobus maintenance officials noted that WMATA is the process of developing new programs 

to monitor and better address failures in fare vending equipment, and to improve radio 

communications. FTAs SMI team found that radio dead spots continue to exist with digital 

system, and that Rail ROCC calls currently “bleed” overtop MTPD calls, occasionally interfering 

with response to incidents. Also, due to the design and use of the radios, and the challenges of 

developing and offering refresher training, bus operators often accidentally push emergency 

alarm buttons, which require response from both BOCC and MTPD. FTA’s SMI team observed 

the high number of the alarms at the BOCC. 

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Despite these efforts, assaults are on the rise and MTPD response to these issues is limited due to 

the constraints of MTPD Officer resources assigned to Metrobus. However, MTPD is attempting 

to proactively address the fare evasion and assault concerns by conducting a Fare Enforcement 

Initiative that will take place in Spring 2015, and also by creating an MTPD office at the 

Shepherd’s Parkway division. This division experiences the highest level of assaults and fare 

evasions. MTPD is assigning its limited resources, both uniformed and casual clothes officers, to 

ride high incident routes at Shepherd’s Parkway and other divisions at times of day when fare 

evasion data indicates incidents spike. This campaign is considered a pilot effort to curb fare 

evasion and assaults and will be evaluated for effectiveness after a reasonable period of 

implementation. 

Required	Actions

Safety Directive 15-1 identifies two required actions to be taken by WMATA to enhance the 

protection of bus operators from assaults and other acts of violence. 

Metrobus Category 1: Concern over the Protection of Metrobus Operations Personnel 

Findings Required Actions (Specified in Safety Directive 15-1) 

Finding B-1 WMATA has not 

addressed operator 

assaults (by passengers) 

at a level commensurate 

with the number of 

occurrences. 

B-1-1-a WMATA must expedite development of an agency-wide, coordinated 

strategy to address contributing elements to Bus Operator Assaults, 

including training, deployment of police and security resources, 

enhanced community outreach, and resolving fare box performance and 

reliability issues. To the extent practical, WMATA should incorporate 

findings from the forthcoming Transit Advisory Safety Committee 

(TRACS) report on this topic. 

B-1-1-b WMATA’s Safety Department must increase its level of involvement in 

the Operator Assault Preventative/Awareness Safety Initiative at Local 

Safety Committees, and in the development of the overall strategy for 

enhanced protection of Bus Operators. 

6.2	 Category B-2: Limited Availability of Training for Operations and 

Maintenance Personnel 

FTA’s SMI team found that although the delivery of new-hire technical training across all 

functions of WMATA Bus Transportation is generally strong, refresher and other training gaps 

exist within the Transportation and Maintenance Departments. 

Situation

Although the delivery of new-hire technical training is generally strong, there is limited refresher 

training offered on a regular and periodic basis for Transportation or Maintenance personnel, and 

WMATA has had difficulty in maximizing the number of participants in the existing courses. 

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•	 Finding B-2: Refresher and other training gaps exist within the Transportation and 

Maintenance Departments. 

Bus Maintenance has an extremely comprehensive and effective new-hire training program for 

bus mechanics that extends over a period of more than two months and covers all necessary 

mechanic skills required to carry out the job function. Bus Maintenance also manages a 

Mechanic Apprentice Program, and requires Automotive Service Excellence (ASE) certification 

of all mechanics. WMATA also provides a cash incentive program for mechanic performance, 

and generally encourages rapport and communication between Maintenance and Operations staff 

at bus divisions to assist in the evaluation of specific mechanical problems or concerns with bus 

vehicles or equipment. Presently, however, while mechanics are required to complete 40 hours 

per year of refresher training, to reinforce previously acquired knowledge and skills with special 

emphasis on safety, this training is not being completed by all mechanics on a regular and 

periodic basis. Due to the demand for mechanics, divisions have faced challenges in making 

mechanics available for this required refresher training. At the time of the SMI, WMATA 

reported that approximately 60 percent of available training slots had been filled by bus 

mechanics. 

New-hire bus operator training takes place initially at the Carmen Turner facility and continues 

at the Division to which a new-hire operator is assigned. This training is comprehensive and 

includes both classroom and behind-the-wheel instruction utilizing division assigned training 

instructors and a cadre of vetted and trained Line Platform Instructors (LPI). Based on document 

reviews by the SMI Team, Bus Transportation training and curriculum meets industry standards. 

However, the lack of availability of satisfactory classroom facilities, training buses, and training 

support technology presents the potential to negatively impact quality of training. Refresher 

training for bus operators is not being carried out as per program requirements. Many bus 

operators that were interviewed stated that they had not received refresher training of any type in 

many years. Training records indicate that refresher training for bus operators lags behind the 

agency’s standards. There are many reasons for the lack of standardized refresher bus operator 

training, including limited availability of training instructor time, the need to carry out extensive 

retraining of bus operators based on performance deficits, and the need to deliver other training 

to bus operators, such as the “We Care” customer service initiative. 

To get caught up, WMATA has set internal goals of providing refresher training for 3-4 bus 

operators daily, which will total 15-20 weekly refresher trainings, 60 monthly trainings, and 

1,200 yearly trainings. While this level of training will not cover the entire bus operations staff, 

WMATA Metrobus personnel believe they can complete refresher training on a two-year cycle. 

Implementation of this program will require dedicated focus and attention to ensure training is 

offered and completed, and that bus operators are made available. 

Training for SOM/street supervisors and SOM/office managers is informal and on-the-job based, 

thus training is not standardized and job performance throughout divisions is inconsistent. 

Training for BOCC Specialists is generally comprehensive but currently does not require a 

proficiency-testing component. BOCC Specialist refresher training is not performed at set 

intervals. Overall, technical skill training documentation within Transportation and Maintenance 

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is comprehensive but compartmentalized. WMATA is working to consolidate training 

documentation within its Enterprise Learning Management system, but consolidation is presently 

incomplete. 

•	 Finding B-3: WMATA does not have a current “BOCC Manual” which lists all 

office procedures and interpretations of rules or instructions pertaining to the 

BOCC Specialist’s duties. There are no checklists available for BOCC Specialists to 

dispatch service or manage incidents. 

FTA’s SMI team also found that the tools used to support training and proficiency of employees 

in the Bus Operations Control Center can be significantly improved. WMATA does not have a 

current “BOCC Manual” which lists all office procedures and interpretations of rules or 

instructions pertaining to the BOCC Specialist’s duties. SOPs give advice on how to assist 

operators with troubleshooting vehicle issues, and the day-to-day rules are an assortment of 

printed memos and emails collected in a three-ring binder that also doubles as the BOCC 

Specialist Training Manual. There are no checklists available for BOCC Specialists to dispatch 

service or manage incidents. FTA’s SMI found that BOCC troubleshooting is not viewed as 

effective by Bus Maintenance personnel, and that, because of the lack of formal documentation 

and refresher training, BOCC does not follow the same SOPs as BMNT for safety critical bus 

items. 

Present protocols are heavy on paperwork, and BOCC Specialists are required to write a paper 

Detention Slip that must be hand-delivered to the “Double 0” at the front of the BOCC in order 

to request a Service Operations Manager (SOM/street supervisor) response to an incident. This 

has the possibility to delay BOCC response to operator issues and emergency situations. There 

are a high number of bus emergency silent alarm activations. Many of these are false alarms due 

to mechanical or operator error, but they require a response from MTPD and an SOM/street 

supervisor. The false alarm issue is compounded by the protocol that does not allow 

communication between the BOCC and an Operator after a silent alarm has been triggered. 

Field observations and interviews conducted by the SMI Team noted that the volume of false 

alarms experienced regularly has created a sense of complacency in the BOCC regarding an alert 

and places a drain on MTPD resources in responding to these false alarms. MetroBus operations 

is considering strategies that could help reduce the number of false alarms, but at this point has 

not determined what those strategies will be. 

Required	Actions

Safety Directive 15-1 identifies two required actions to be taken by WMATA to address 

limitations in available operations and maintenance training. 

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Metrobus Category 2: Limited Availability of Training for Operations and Maintenance Personnel 

Findings Required Actions (Specified in Safety Directive 15-1) 

Finding B-2 Refresher and other 

training gaps exist within 

the Transportation and 

Maintenance Departments. 

B-2-2-a WMATA must develop a strategy and approach for developing, offering 

and updating refresher training as required in current policies and 

standards, for key categories of Transportation and Maintenance 

personnel, including Bus Operators, Street Supervisors, Bus Operations 

Control Center Specialists, and Bus Maintenance personnel. 

Finding B-3 WMATA does not have a 

current “BOCC Manual” 

which lists all office 

procedures and 

interpretations of rules or 

instructions pertaining to 

the BOCC Specialist’s 

duties. There are no 

checklists available for 

BOCC Specialists to 

dispatch service or 

manage incidents. 

B-2-3-a WMATA must develop a Bus Operations Control Center Manual (with 

processes and procedures for Bus Controller Specialists) and a 

complete set of checklists for implementing Standard Operating 

Procedures and bus vehicle troubleshooting guidance. A clear 

accompanying process should be established for updating the Manual 

and training Specialists on its contents and updates. 

6.3	 Category B-3: Inconsistent Operational Testing and Rules 

Compliance Checks 

To ensure the proficiency, professionalism, and safety of bus operations staff, transit agencies 

establish programs to conduct announced and unannounced operational testing. FTA’s SMI 

determined that, in a few key areas, announced and unannounced testing of bus operations 

personnel is not being conducted consistently or effectively. 

Situation

•	 Finding B-4: Bus pre-trip inspections are not being completed, documented, or 

monitored to the degree necessary to comply with internal WMATA SOPs or with 

industry standards. 

FTA’s SMI team identified through onsite visits of six Metrobus garages and numerous 

interviews with bus operators, depot clerks, and other WMATA staff that bus pre-trip inspections 

are not being completed, documented, or monitored to the degree necessary to comply with 

internal WMATA SOPs or with industry standards. The bus pre-trip inspection form becomes 

part and partial to the legal operation of a bus under the federal and state issue of a Commercial 

Driver’s License (CDL). 

FTA’s SMI team informed WMATA leadership that the industry standard for time allotted to 

complete an inspection is 15 minutes. WMATA bus operators are allotted ten minutes from 

check-in to pull out to complete a comprehensive pre-trip inspection. The clock starts once the 

operator checks in with the fare clerk. In most divisions the operator must then walk downstairs 

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and out to the bus yard, contact the Dispatcher for a bus assignment, and then walk across a large 

yard to find their bus. 

FTA’s SMI team noted at the Four Mile Division that Operators might be sent to a remote yard 

that requires accessing three different crosswalks to retrieve a vehicle. The ten minutes may 

have expired before the operator has reached the vehicle, prohibiting the possibility that 

operators can carry out a comprehensive pre-trip in the amount of time allotted. Observations 

and reviews of pre-trip cards by the SMI team indicated a large number of operators conduct 

only a cursory inspection, or none at all, due to lack of time allotted. 

This has the possibility of exposing WMATA to liability in the case of death or injury resulting 

from a bus accident. Also, there appears to be an inadequate definition of a pre-trip inspection 

and lack of standardized communication on precisely how to complete the pre-trip inspection 

form. Fare Clerks at several divisions were unable to communicate to the SMI team what a 

properly completed pre-trip inspection form would look like. It also should be noted that 

WMATA uses one standard bus condition card (pre-trip inspection card) for all years, makes and 

models of vehicles. 

FTA’s SMI team uncovered indicators that bus operators and depot clerks do not fully 

understand the importance of the quality of pre-trip inspections and the implications of a less 

than comprehensive inspection, not only on passenger safety, but their own, as well. 

FTA’s SMI team finds that this issue affects the ability of maintenance to carry out its function, 

increases the potential for road calls, and lowers the safety profile of buses put into service. 

There appears to be limited enforcement of pre-trip inspections by management, including 

SOM/Office Managers and Assistant Superintendents. 

•	 Finding B-5: Within WMATA Bus Transportation, there are limited formal 

evaluations being conducted of the proficiency of bus operators. Although there are 

evaluation checklists and protocols to measure performance and proficiency of 

WMATA bus operators, the application of this process is not expansive, uniform, 

nor structured within established timeframes. 

FTA’s SMI team also found that within WMATA Bus Transportation, there are limited formal 

evaluations being conducted to assess the proficiency of bus operators. Although there are 

evaluation checklists and protocols to measure performance and proficiency of WMATA bus 

operators, the application of this process is not uniform and structured within established 

timeframes. New-hire bus operators are formally evaluated after 30, 60 and 90 days; beyond 

that, on-board bus operator evaluations are randomly carried out by a variety of WMATA staff, 

including CQAL, supervisors and others. 

For example, CQAL does the Passenger Service/ Operator Skills Audits, but very few of these 

ride checks take place compared to the number of vehicles in service and operators at Metrobus. 

FTA’s SMI team found that, generally, bus operators that have been identified as needing 

retraining are formally evaluated, but those operators that do not need retraining are not regularly 

evaluated due to lack of staffing resources available to carry out these evaluations. Industry 

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standards, and WMATA’s requirements specify that as part of annual refresher training 

requirements for all bus operators, behind-the-wheel Operator performance should be evaluated. 

However, because refresher training is not carried out regularly per this standard, formal 

evaluations of bus operators are not taking place as planned for and required. 

WMATA has committed to strengthening its bus operation evaluation program, and also is using 

its new DriveCam program to monitor operator performance and identify operators in need of retraining or priority evaluation. 

•	 Finding B-6: WMATA BOCC Specialists and SOM/Street Supervisors are excluded 

from WMATA’s fatigue management program. 

Finally, as noted in other sections of this report, FTA’s SMI team commends WMATA for their 

industry-leading fatigue management program, which takes a science-based approach to limit the 

effects of fatigue on safe delivery of services. FTA’s SMI team found that BOCC Specialists 

and SOM/street supervisors; however, have been excluded from this program. Given concerns 

regarding lengthy shifts with limited breaks, FTA’s SMI team believes that WMATA’s excellent 

program should be expanded to include BOCC Specialists and SOM/street supervisors. 

Required	Actions

Safety Directive 15-1 identifies four required actions to be taken by WMATA to improve the 

performance of operational testing and rules compliance checks. 

Metrobus Category 3: Inconsistent Operational Testing and Rules Compliance Checks 

Findings Required Actions (Specified in Safety Directive 15-1) 

Finding B-4 Bus pre-trip inspections B-3-4-a WMATA must assess its overall approach to the performance of pre-trip 

are not being completed, inspections to determine the adequacy of time available for Operators to 

documented, or monitored perform these inspections, the level of training available to Operators 

to the degree necessary to regarding the conduct of these inspections, and whether additional 

comply with internal condition cards should be developed for different sub-fleets. 

WMATA SOPs or with 

industry standards. 

Finding B-5 Within WMATA Bus 

Transportation, there are 

limited formal evaluations 

being conducted of the 

proficiency of Bus 

Operators. Although there 

are evaluation checklists 

and protocols to measure 

performance and 

proficiency of WMATA Bus 

Operators, the application 

of this process is not 

expansive, uniform, nor 

structured within 

B-3-5-a WMATA must establish and enforce a formal program to ensure that 

Supervisors assess Bus Operator performance. 

B-3-5-b WMATA must expand the total number and frequency of Passenger 

Service / Operator Skills Audits performed by Corporate Quality 

Assurance. 

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Metrobus Category 3: Inconsistent Operational Testing and Rules Compliance Checks 

Findings Required Actions (Specified in Safety Directive 15-1) 

established timeframes. 

Finding B-6 WMATA BOCC Specialists 

and SOM/Street 

Supervisors are excluded 

from WMATA’s fatigue 

management program. 

B-3-6-a WMATA must establish a strategy and timeframe for extending the 

Fatigue Risk Management Program to all Bus Operations Control 

Center staff, including BOCC Specialists and the Street Operations 

Managers (SOMs), formerly Street Supervisors. 

6.4 Category B-4: System-wide Maintenance Issues 

FTA’s SMI team finds that WMATA experiences safety and reliability issues with some newly 

procured parts (i.e., bearings). WMATA employees noted that there is no formal testing process 

for newly procured parts to ensure their quality prior to implementation. 

Situation

•	 Finding B-7: The bus maintenance materials procurement process is not being 

executed in accordance with FTA standards meant to ensure the safety and quality 

of parts being purchased (FTA Circular 4220.1F). 

FTA’s SMI team found that the bus maintenance materials procurement process is not being 

executed in accordance with FTA standards meant to ensure the safety and quality of parts being 

purchased. During the materials procurement process bus maintenance is asked to submit the 

salient characteristics to comply with FTA Circular 4220.1F. These characteristics are meant to 

ensure that there is both a competitive bid process as well as assurance that the procured parts 

meet their required size, life cycle, and reliability standards. During the interview process, 

WMATA employees noted reliability issues with materials procured through this method, 

including Absorbed Glass Mat (AGM) batteries, exhaust gas recirculation valves, and cooling, 

ignition and other emission system components. 

FTA’s SMI team found that WMATA does not have a for quality control process for newly 

procured parts to ensure their quality prior to implementation, though Bus Maintenance has both 

quality assurance and configuration management procedures at their disposal. FTA’s SMI team 

found that new parts are procured and immediately installed onto vehicles. 

This lack of review of newly procured parts presents the potential for reduced performance of the 

WMATA bus fleet as well as an increased safety risk for WMATA’s passengers. Bus 

Maintenance should examine their process for both determining the salient characteristics of 

needed parts and testing the quality of parts received to ensure they meet required standards. 

WMATA’s Metrobus system has committed to developing a more formal quality control process 

for parts. 

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• Finding B-8: Newly delivered buses have body, system, and component problems. 

WMATA’s Metrobus fleet reliability fell by 13 percent in 2014, as a result of mechanical 

failures causing buses to go out of service more frequently. Prior to 2014, bus fleet reliability had 

improved an average of 4.3% per year since 2003. While WMATA has set a performance goal of 

8,000 miles between failure for its bus fleet in 2015, the agency is currently averaging about 

6,535 miles between failure. Rates of failure so far in 2015 continue the downward trend in bus 

reliability. 

FTA’s review of maintenance records and incident reports indicated an unusually high number 

of defects and maintenance activities associated with recently purchased vehicles and vehicles 

less than 3 years old. During an interview with the engineer in charge, he indicated that the 

newly delivered buses seem to have too many body, system, and component problems, 

particularly with electronic and software components that were not previously discovered during 

WMATA’s in-plant bus inspection process. FTA’s requirements for this process, found at 49 

CFR § 663.37, are designed to ensure that vehicles purchased with Federal funds meet contract 

requirements, including performance standards for reliability. FTA’s requirements specify that 

grant recipients, purchasing 10 or more buses or vans with Federal funds, must conduct an inplant inspection process to oversee and monitor the construction and assembly of the vehicles. 

This requirement does not specify that a resident inspector remain "full-time" at the 

"manufacturer’s site throughout the period of manufacture." Although this may be recommended 

for some vehicle procurements, FTA’s inspector requirement may be fulfilled through the use of 

periodic visits. For buses or vans produced by multiple manufacturers, the inspector is only 

required to visit the final stage manufacturer’s facility. 

While the in-plant inspector is required for purchases of ten or more buses or vans, the recipient 

must be certain that the inspector’s report is equally comprehensive, regardless of the choice of 

inspection services. The number of visits and the length of each visit should be based on the 

recipient’s level of comfort with the manufacturer’s capabilities. It is the recipient’s 

responsibility to ensure that the vehicles comply with the contract specifications. The purpose of 

the resident inspector’s report is to assist the recipient in verifying that the vehicles meet the 

contract specifications. 

It was reported to FTA’s SMI that WMATA’s Corporate Quality Assurance or CQAL staffing 

has decreased from 21 to 11 in the past few years, and that, as a result, CQAL no longer visits 

factory for inspections prior to bus acceptance, and the CQAL role is limited to acceptance 

testing only. WMATA’s executive leadership team indicated that staffing had not been 

significantly reduced in CQAL because roles and responsibilities for specific bus quality 

assurance functions had also been re-distributed. 

SAFE previously sent two representatives to perform an in-plant vehicle inspection, however 

WMATA staff reported that this inspection was not as thorough as a typical CQAL inspection, 

because it focused on different activities (safety certification versus quality inspection and 

control). In interviews, a wide range of WMATA’s maintenance personnel attributed worsening 

bus vehicle performance to reduction in oversight of the bus vehicle manufacturing process. 

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Another source of concern regarding the condition of newer vehicles identified by FTA’s SMI 

team related to vacancy rates and turnover of bus mechanic positions. WMATA’s bus 

maintenance managers indicated that they are struggling to keep employees due to competition 

from the attractiveness of moving to rail or to outside of WMATA. In some divisions, two in 10 

bus mechanic positions may be open, much higher than the 6 percent WMATA vacancy rate 

agency wide. This is due in large part to more attainable hiring standards for bus mechanics than 

the more specialized and less common requirements of an elevator/escalator or rail vehicle 

mechanic. A sizable percentage of WMATA bus maintenance staff has significantly fewer years 

of experience than their counterparts in rail or ELES. 

This situation is complicated by the lack of administrative staff available to support all days and 

shifts in WMATA’s bus maintenance facilities. Lack of support staff places a greater burden of 

paperwork and administrative tasks on schedule maintenance supervisors, which affects the 

ready availability of guidance and support for mechanics. 

Required	Actions

Safety Directive 15-1 identifies two required actions to be taken by WMATA to address safety 

deficiencies related to system-wide maintenance issues. 

Metrobus Category 4: System-wide Maintenance Issues 

Findings Required Actions (Specified in Safety Directive 15-1) 

Finding B-7 The bus maintenance 

materials procurement 

process is not being 

executed in accordance 

with FTA standards meant 

to ensure the safety and 

quality of parts being 

purchased (FTA Circular 

4220.1F). 

B-4-7-a WMATA must develop and implement a plan to bring its bus 

maintenance materials procurement process into compliance with FTA 

Circular 4220.1F. This plan must include a formal testing process for 

newly procured parts and enhancements to the process currently used 

to accept new bus vehicles. 

Finding B-8 Newly delivered buses 

have body, system, and 

component problems. 

B-4-8-a WMATA must conduct a resource evaluation regarding overall staffing 

and resources available to Corporate Quality Assurance and to other 

quality divisions and departments within Bus Maintenance and Bus 

Operations to support in-plant inspection and general maintenance 

materials procurement. Options to re-instate factory visits must also be 

considered as part of this assessment. 

6.5 Category B-5: Lack of Information Management System Technology 

FTA’s SMI team identified two findings related to automated systems and how enhanced 

information management could greatly improve Metrobus safety processes. 

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Situation
 

•	 Finding B-9: Insufficient staffing and tools in place for collecting available Bus 

Operations data to support more proactive analysis from a safety perspective. 

FTA’s SMI team generally found in interviews and field observations that neither Metrobus 

divisions nor the BOCC had sufficient staff to effectively enter, manage and analyze paper-based 

records. FTA’s SMI team noted numerous vacancies in office manager positions and support that 

previously handled the data entry and management workload and supported the proactive 

collection and analysis of operations information and data. 

FTA’s SMI team generally found that while WMATA’s Safety Department continues to expand 

and enhance its program activities, more can be done to support WMATA’s Metrobus 

Transportation and Maintenance Departments in identifying and managing safety issues and 

concerns. Throughout the conduct of the SMI, FTA’s team found additional opportunities for 

SAFE to conduct more proactive analysis of information identified by Metrobus Transportation 

and Maintenance departments. 

•	 Finding B-10: Proactive safety analysis of information provided by Operating and 

Maintenance departments is not routinely conducted. This negatively impacts 

ability of WMATA to provide more support for proficiency testing, conduct more 

in-depth safety studies, reviews and accident/incident investigations. 

The existing Safety Measurement System software is an industry best practice and an 

extraordinary tool for documenting, tracking and analyzing accident and incident data. It 

provides a strong database for accident and incident risk mitigation development. However, by 

nature, it is a reactive tool that comes into play fully after an accident occurs and does not serve 

as effectively as it could as a proactive tool in non-event hazard identification and analysis. 

Independent of the Safety Measurement System, hazard identification data is often not captured 

or the documentation of data is not centralized. Individual employees very often identify hazards 

and respond to them unilaterally without collecting data about the hazard and the mitigation in a 

centralized data pool. This lack of information and centralized documentation limits WMATA’s 

ability to be proactive in its hazard and risk mitigation processes and also affects the monitoring 

of risk mitigation strategies. Although SAFE pursues root cause analysis of accidents that reach a 

Level 1 rating, analyses are often not conducted on lower level accidents. Equally, root cause 

analysis for lower level events at the division level is limited. A lower level accident has the 

potential to become a Level 1 accident if risk is not assessed and proactive risk mitigation 

strategies go unexplored. 

WMATA utilizes the Local Safety Committees (LSC) at the division level to identify safety 

concerns and hazards. The SMI team found that there was no formal procedure for elevating 

safety concerns to the Department Safety Committee (DSC). One LSC in particular believed 

their concern was being actively addressed by the DSC when in fact the item had not been added 

to the DSC agenda. 

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A Safety Officer is not attached to each bus division so the role of the Safety Officer within a 

division is not as powerful as it could be. Safety Officers are often spread thin in trying to carry 

out their safety support mission. Additionally, each Safety Officer does not have an assigned 

response vehicle, making it difficult to respond to events that are a part of their safety job 

responsibilities. 

Interviews and observations by the SMI teams indicated that Safety Officer duties and 

responsibilities are not as clearly defined as they could be, thus creating a lack of standardization 

of Safety Officer responsibilities that could possibly lead to certain job requirements going 

unaddressed. 

Required	Actions

Safety Directive 15-1 identifies three required actions to be taken by WMATA to enhance the 

use and performance of information technology on Metrobus. 

Metrobus Category 5: Lack of Information Management System Technology 

Finding B-9 Insufficient staffing and tools 

in place for collecting 

available Bus Operations 

data to support more 

proactive analysis from a 

safety perspective. 

B-5-9-a Conduct an assessment determining the adequacy of resources 

available to support Bus Operations Control Center and Bus 

Superintendents with data entry and analysis. 

Finding B-10 Proactive safety analysis of 

information provided by 

Operating and Maintenance 

departments is not routinely 

conducted. This negatively 

impacts ability of WMATA to 

provide more support for 

proficiency testing, conduct 

more in-depth safety 

studies, reviews and 

accident/incident 

investigations. 

B-5-10-a WMATA must formalize the procedure for how a Local Safety 

Committee will elevate a safety concern to the Departmental Safety 

Committee. 

B-5-10-b WMATA must define the Bus Safety Officer roles and responsibilities 

and conduct an assessment determining the adequacy of resources 

available for Bus Safety Officers to complete these responsibilities. 

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Appendix A: WMATA Safety Actions 

The Washington Metropolitan Area Transit Authority (WMATA) ordered fourteen early-action 

safety items in advance of the National Transportation Safety Board’s (NTSB) report on the 

January 2015 L’Enfant Smoke Incident: 

1.	 Create a Standard Operating Procedure (SOP) to require train operators to cut the train’s 

environmental system (EV) immediately upon entering a smoke condition and 

independently of outside instruction. Previous SOPs permitted the train operator to cut 

the EV only after receiving instruction from the Rail Operations Control Center (ROCC). 

2.	 Create an incident management SOP that requires personnel within the ROCC to 

maintain their desk location for the duration of the incident management process. This 

SOP is intended to reduce distraction from unnecessary interactions. 

3.	 Set a schedule for quarterly emergency drills in coordination with the Metro Transit 

Police Department (MTPD) to encompass the next three years. The drill location shall 

rotate among a station, tunnel, and elevated portion of the wayside. Each drill shall also 

rotate among jurisdictions. 

4.	 Design and implement signage for exterior doors to clearly identify emergency access 

points. This signage will assist emergency responders in identifying and utilizing 

emergency doors and access points. 

5.	 Conduct inspections on all third rail jumper cables located in tunnel sections and provide 

an engineering and operations report on condition and installation. 

6.	 Replace high voltage third rail jumper cables with low smoke/low halogen cables. This 

project is part of an on-going rehabilitation program. 

7.	 Install mechanical protection on third rail jumper cables potentially exposed to wear from 

vibration against other materials. 

8.	 Inspect and review ground fault detectors on third rail circuit breakers. 

9.	 Perform an operational analysis to determine whether WMATA can limit current flow 

through the electrical infrastructure by running trains at 45 miles per hour in the system 

core. 

10. Determine the feasibility of and report on installing zoned smoke detectors, including 

wireless detectors, using Emergency Trip Station (ETS) boxes to relay location and other 

data. 

11. Replace or rehabilitate all lights in WMATA tunnels via a multi-year maintenance 

program. 

12. Create a dedicated maintenance crew to continuously clear tunnel passageways of debris, 

equipment, or other potential obstructions. 

13. Review protocols for alarms in the ROCC and identify critical versus non-critical 

notifications. 

14. Establish a ventilation system testing quality audit process to ensure compliance with 

established maintenance and testing practices. 

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Appendix B: NTSB Safety Recommendations to WMATA 

ACCIDENT 

DATE DESCRIPTION FATALITIES INJURIES EST. PROPERTY DAMAGE 

NUMBER OF SAFETY 

RECOMMENDATIONS TO 

WMATA 

RECOMMENDATION STATUS AS OF 

4/29/2015 

1/13/1982 Derailment of Train 410 at Smithsonian 

Interlocking, Washington, DC. 3 25 $1.3 M 34 

27 Closed: Acceptable Action 

3 Closed: Acceptable Alternate Action 

4 Closed: Unacceptable Action 

6/19/1987 

Derailment of CSX Corporation freight 

railcars fouling Metrorail Red Line track near 

Takoma Park, MD station. 

0 0 Not reported 2 2 Closed: Acceptable Action 9/5/1987 

Derailment of CSX Corporation freight 

railcars fouling Metrorail Red Line track near 

Fort Totten Station, Washington, DC. 

9/17/1987 

Fouling of Metrorail Red Line track near 

Silver Spring, MD Station due to debris from 

a CSX Corporation train striking heavy 

construction equipment on CSX track. 

1/9/1996 Collision of Train T-111 with standing train at 

Shady Grove Station, Gaithersburg, MD. 1 0 Between $2.1M 

and $2.6M 20 

18 Closed: Acceptable Action 

1 Closed: Acceptable Alternate Action 

1 Closed: Superseded 

11/3/2004 

Collision Between Train 703 and Train 105 at 

the Woodley Park-Zoo/Adams Morgan 

Station, Washington, DC. 

0 20 $3.5M 3 

2 Closed: Acceptable Action 

1 Closed: Unacceptable Action 

5/14/2006 

Red Line Train Striking WMATA Wayside 

Worker near Dupont Circle Station, 

Washington, DC. 

1 0 Not reported 4 

3 Closed: Acceptable Action 

1 Closed: Acceptable Response 

11/30/2006 

Yellow Line Train Striking WMATA Wayside 

Workers near Eisenhower Avenue Station, 

Alexandria, VA. 

2 0 Not reported 

4 (identical to the 4 Recs. 

issued after the 5/14/2006 

accident) 

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ACCIDENT 

DATE DESCRIPTION FATALITIES INJURIES EST. PROPERTY DAMAGE 

NUMBER OF SAFETY 

RECOMMENDATIONS TO 

WMATA 

RECOMMENDATION STATUS AS 

OF 4/29/2015 

Derailment of Train 504 near the Mount Vernon 

5 Closed: Acceptable Action 

1/7/2007 Square Station, Washington, DC. 0 0 $3.8M 6 

1 Closed: Acceptable Alternate 

Action 

14 Closed: Acceptable Action 

6/22/2009 Collision of Train 112 and Train 214 near the Fort 

Totten Station, Washington, DC. 9 52 $12M 18 1 to WMATA Board 

1 Closed: Superseded 

3 Open: Acceptable Response 

1 Closed: 

(Board) Acceptable Action 

11/29/2009 Collision of Train 902 with standing train at West 

Falls Church Station, Falls Church, VA. 0 2 $9M 0 N/A 

WMATA Hi-Rail Maintenance Vehicle Striking 

1/26/2010 WMATA Wayside Workers near Rockville Station, 2 0 Not reported 0 N/A 

Rockville, MD. 

2/12/2010 Derailment of Train 156 near the Farragut North 

Station, Washington, DC. 0 3 $174,000 0 N/A 

1/12/2015 

Smoke and electrical arcing accident between the 

L’Enfant Plaza Station and Potomac River Bridge, 

Washington, DC. 

1 86 Under 

investigation 

Under investigation 

3 Urgent 

1 Safety Recommendation 

Under investigation 

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Appendix C: Safety Directive 15-1 Tracking Matrix 

WMATA SMI Findings and Required Action Matrix 

Findings by Category Required Action (Safety Directive 15-1)

by Category 

Metrorail Category 1: Inadequate Rail Operations Control Center Staffing and Procedures 

Finding R-1 WMATA’s Rail Operations Control 

Center is significantly understaffed. 

R-1-1-a WMATA must fully staff the Rail Operations Control Center. 

Finding R-2 RTC re-certification has not 

occurred as required. 

R-1-2-a WMATA must complete and maintain required annual recertifications for Rail Traffic Controllers. 

Finding R-3 RTCs receive limited refresher 

training and no road days. 

R-1-3-a WMATA must establish a program to provide each Rail Traffic 

Controller with mandatory road days for territory familiarization 

and to keep up with changing system elements. 

R-1-3-b WMATA must require all Rail Traffic Controllers to obtain and 

maintain Level 4 Roadway Worker Protection training and 

certification. 

Finding R-4 There is a high level of noise and 

distraction in the ROCC, and a lack 

of electronic controls in the AIM 

system to prevent errors. 

R-1-4-a WMATA must complete its assessment regarding the 

identification of critical versus non-critical notifications and 

alarms in the Rail Operations Control Center, and options for 

removing non-critical notifications must be implemented. 

R-1-4-b WMATA must conduct an engineering assessment, and 

implement the results regarding options to reduce noise in the 

Rail Operations Control Center, including ambient noise and 

feedback from the radio system. 

R-1-4-c Until such time as electronic records of train movement are 

readily available to on-duty Rail Traffic Controllers, WMATA 

must ensure that its Rail Traffic Controllers maintain a paperbased record of all mainline train movements, signal bypasses, and unusual movements. 

Finding R-5 WMATA RTCs are required to 

perform many tasks outside of 

industry standards. 

R-1-5-a WMATA must ensure Rail Traffic Controller workload and 

distraction do not interfere with the safe and efficient movement 

of trains. 

Finding R-6 Radio discipline is poor. R-1-6-a WMATA must establish and enforce a proper protocol for 

language and terminology that is used over the radio – to 

include 100 percent word-for-word read-back for safety-related 

instructions and unusual train movements. 

R-1-6-b As part of the radio protocol required in R-1-6-a, WMATA must 

establish an approach for communicating and managing all 

speed restrictions that requires two-way communication 

between the ROCC and train operator and takes full advantage 

of available electronic AIM system features. 

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WMATA SMI Findings and Required Action Matrix 

Findings by Category Required Action (Safety Directive 15-1)

by Category 

Finding R-7 WMATA’s ROCC lacks formal 

procedures, manuals and checklists 

R-1-7-a WMATA must establish procedural checklists for Rail 

Operations Control Center staff to implement the Standard 

Operating Procedures attached to the Metrorail Safety Rules 

and Procedures Handbook. 

R-1-7-b WMATA must enhance RTC reference materials to direct 

internal operations at the Rail Operations Control Center, 

including the use of the Advanced Information Management 

system, visual schematics of WMATA stations and facilities, 

and internal ROCC administrative policies and procedures. 

Finding R-8 Personal cell phones are used by 

RTCs in the ROCC. 

R-1-8-a WMATA must establish a clear policy that prohibits distractions 

from the use of cell phones and other electronic devices in the 

Rail Operations Control Center. 

Finding R-9 No formal transfer records are used 

when RTCs complete shift briefings. 

R-1-9-a Until such time as electronic transfer records are implemented, 

WMATA must ensure that its Rail Traffic Controller use paperbased logs with formal signatures. 

Finding R-10 WMATA does not use industry 

standard rules reviews and scenario 

testing activities. 

R-1-10-a WMATA must establish an on-going “efficiency” testing 

program for Rail Traffic Controllers to evaluate their in-service 

performance and competency. 

Finding R-11 WMATA faces major challenges in 

recruiting and training new RTCs. 

R-1-11-a WMATA must establish an independent committee to evaluate 

and monitor the recruitment of Rail Traffic Controller trainees, 

the quality and performance their training, and the certification 

of new candidates. 

Finding R-12 WMATA’s training program for new 

RTCs is inadequate. 

R-1-12-a WMATA must overhaul, correct, revise and improve its training 

program for Rail Traffic Controllers. 

R-1-12-b WMATA must establish performance standards to be qualified 

for all positions in the Rail Operations Control Center. 

Finding R-13 WMATA’s accident investigation 

process does not look at the ROCC 

or individual RTCs. 

R-1-13-a WMATA must expand the focus of its accident investigation 

process to include an active review of the actions of the ROCC, 

and to ensure that RTCs whose performance could have 

contributed to the accident are taken for mandatory postaccident drug and alcohol testing as per 49 CFR Part 655.44. 

Finding R-14 While it has improved, the quality of 

WMATA’s radio system is still poor 

in some locations. 

R-1-14-a WMATA must expedite activities underway to modify the radio 

system design to add coverage to the areas that currently are 

not part of the system design, including tunnel ventilation and 

fan shafts, safe and refuge areas, and tunnel portals. 

R-1-14-b WMATA must assess and prioritize for additional radio 

enhancements not covered by Capital Improvement Plan (CIP) 

136. 

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WMATA SMI Findings and Required Action Matrix 

Findings by Category Required Action (Safety Directive 15-1)

by Category 

Metrorail Category 2: Ineffective Training, Operational Testing and Rules Compliance Programs 

Finding R-15 Maintenance and Operations 

Departments have not ensured the 

RWP training program is being 

conducted as required. Annual 

refresher and biennial recertification requirements for Level II 

and Level IV are behind schedule. 

R-2-15-a Each WMATA Department with Roadway Worker Protectiontrained and qualified employees must coordinate with Technical 

Skills & Maintenance Training to get or establish an accurate 

status on each employee’s refresher and requalification 

training. 

R-2-15-b Each WMATA employee with lapsed refresher training or 

requalification must repeat the initial training and qualification 

for his or her level as specified in WMATA’s roadway worker 

protection training program. 

R-2-15-c WMATA’s Information Technology Department must work with 

Technical Skills & Maintenance Training to develop a long-term 

solution to tracking employee status and ensuring that 

Computer-Based Training records, classroom records and 

employee records are accessible to all departments. 

R-2-15-d WMATA must include annual Roadway Worker Protection 

refresher and requalification time in overall work scheduling 

protocols and requirements. 

Finding R-16 Technical Training for operations 

and maintenance departments is 

under-resourced and fractured, 

currently provided by five different 

departments and IT, is insufficiently 

directed and resourced, and relies 

significantly on on-the-job-training 

(OJT) which is informal and lacks 

oversight. 

R-2-16-a WMATA must conduct a coordinated study to prioritize 

technical training needs for maintenance personnel, and 

operations training for Rail Traffic Controller, Train Operators, 

and Field Supervisors. 

R-2-16-b WMATA must evaluate whether re-organization or 

consolidation of training functions would improve the agency’s 

ability to manage, schedule, budget for, develop, oversee and 

assess training and ensure that training material remains up-todate. 

R-2-16-c WMATA must establish a comprehensive training program to 

communicate the new “Fire Life Safety 1000 -- Inspection, 

Testing and Maintenance Procedure” to WMATA Operations 

and Maintenance personnel. 

R-2-16-d WMATA must establish formal guidance for maintenance 

employees responsible for providing on-the-job training. 

Finding R-17 WMATA does not have a clear 

strategy for the development or 

delivery of emergency response 

training to WMATA’s frontline 

personnel, or for managing the 

logistical challenges associated with 

coordinating familiarization training 

R-2-17-a WMATA’s Office of Emergency Management must conduct a 

formal review of the Metrorail Safety Rules and Procedures 

Handbook, the supporting Standard operating Procedures, and 

the new checklists and tools developed by the Rail Operations 

Control Center to ensure conformance with WMATA’s 

emergency plans and the understanding of local jurisdictions as 

reflected in region-wide emergency operations plans. 

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WMATA SMI Findings and Required Action Matrix 

Findings by Category Required Action (Safety Directive 15-1)

by Category 

with local emergency responders. R-2-17-b WMATA’s Office of Emergency Management must conduct a 

formal review of all training provided to frontline, supervisory 

and ROCC personnel regarding the actions required to be 

performed during an emergency to ensure its conformance with 

WMATA’s emergency plans and the understanding of local 

jurisdictions as reflected in region-wide emergency operations 

plans. 

R-2-17-c WMATA must establish an approach for delivering updated 

emergency response training to front-line Train Operators, 

Supervisors, Stations Managers, Rail Traffic Controllers, and 

other personnel. 

R-2-17-d WMATA must review and update its approach to providing 

familiarization training to local emergency responders, and 

ensure that emergency responders have ample opportunities to 

learn and practice activating and using fire life safety 

equipment and systems, including ventilation fans, fire 

suppression system, standpipes, communication equipment, 

and other systems. 

R-2-17-e WMATA must test its backup Rail Operations Control Center 

on a quarterly basis and demonstrate the ability to safely 

control train traffic. 

Finding R-18 Rules compliance checks of 

operational personnel are 

inconsistent. 

R-2-18-a WMATA must require Rail Supervisors to complete meaningful 

rules checks on Train Operators, not just single observation 

items, unless directed as part of a special emphasis program. 

R-2-18-b WMATA must establish documentation and a training program 

to ensure that Rail Supervisors know how to conduct and 

record meaningful rules checks of Train Operators, and how to 

discuss results with Train Operators. 

Finding R-19 Rail Transportation is not ensuring 

that field supervisors conduct 

required rules compliance checks 

on station managers and train 

operators. 

R-2-19-a WMATA must develop a formal operations testing program to 

include active, fail-safe testing of all employees responsible for 

operating or directing the safe movement of trains. 

R-2-19-b WMATA must document operational testing requirements and 

test results to improve the utility of the program as part of a 

robust testing and observation program. 

Finding R-20 New supervisors are not familiar 

with rules compliance checks 

requirements. 

R-2-20-a WMATA must improve the quality and consistency of training 

for new Rail Supervisors to include purpose and requirements 

for rules checks. 

Finding R-21 Some newly promoted Field 

Supervisors, who have not 

previously operated rail vehicles, 

R-2-21-a WMATA must establish a minimum number of trips per month 

that each Rail Supervisor must complete on the mainline to 

ensure the sufficiency of his or her skills. 

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WMATA SMI Findings and Required Action Matrix 

Findings by Category Required Action (Safety Directive 15-1)

by Category 

are not sufficiently trained to relieve 

train operators on the mainline. 

R-2-21-b WMATA must review Supervisor Daily Activity Reports to 

ensure that Supervisors are completing required activities, 

including the minimum number of established trips per month. 

Finding R-22 WMATA must ensure that two-year 

re-certifications are being performed 

for Train Operators. 

R-2-22-a WMATA must review its schedule of in service evaluations to 

ensure sufficient time is available for each Train Operator to 

receive his or her two-year re-certification. 

R-2-22-b WMATA’s Information Technology Department must work Rail 

Operations Support to develop a long-term solution to tracking 

Train Operator re-certification status and the results of any 

other in service examinations or activities completed. 

Metrorail Category 3: Insufficient Track Time for Maintenance 

Finding R-23 Current OWL nighttime 

maintenance window typically only 

allows between 90 minutes and two 

hours of on track time. 

R-3-23-a WMATA must ensure that a process is in place for identifying 

and scheduling sufficient track time to complete required 

inspection, testing and maintenance activities. 

Finding R-24 WMATA has reduced other options 

for track access, including holiday 

weekend work shut-downs, early 

outs, and single-tracking. 

R-3-24-a WMATA must establish firm limits on minimum track time for 

inspection, testing and maintenance activities per month, and 

revisit limits annually. 

Finding R-25 Due to lack of track time, WMATA’s 

maintenance departments must 

consistently re-schedule work, and, 

as a result, have growing 

maintenance backlogs, dating back 

to 2012 and 2013 

R-3-25-a WMATA must develop and implement staffing plans to 

eliminate maintenance work orders backlogs and manage ongoing workload in track and structures, traction power, 

communications, and automated train control departments. 

Finding R-26 Efficiencies can be obtained to 

improve the way in which WMATA’s 

workers and contractors currently 

access the right-of-way. 

R-3-26-a WMATA must improve interdepartmental coordination and 

communication to take full advantage of track time. 

Metrorail Category 4: System-wide Maintenance Issues 

Finding R-27 Documented maintenance 

procedures and standard operating 

procedures are not implemented as 

required. 

R-4-27-a For all major departments with inspection and maintenance 

responsibilities for critical infrastructure, WMATA must 

establish and/or update a preventive maintenance and 

inspection testing quality audit process to ensure compliance 

with established maintenance and testing practices, and to 

monitor missed or incomplete preventive maintenance activities 

and/or inspections. 

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Final Report – Safety	Management Inspection

Washington Metropolitan Area Transit Authority

WMATA SMI Findings and Required Action Matrix 

Findings by Category Required Action (Safety Directive 15-1)

by Category 

Finding R-28 Walking track inspection resources 

have been cut in half. 

R-4-28-a WMATA must review the workload and inspection territory 

assigned to track inspectors, and leverage non-track inspectors 

to perform watchman duties. 

Finding R-29 All ATC alarms and issues must be 

communicated to ATC for 

investigation, repair and analysis. 

R-4-29-a WMATA must ensure that ROCC reports all signal alarms and 

notifications to ATC. 

Finding R-30 WMATA’s program for measuring, 

documenting and addressing the 

potential impacts of stray negative 

return current on the condition of 

WMATA’s infrastructure is not 

documented in a formal plan to 

ensure coordination across 

departments and contractor 

services. 

R-4-30-a WMATA must develop a plan to document roles and 

responsibilities, activities, and points of coordination regarding 

its program to measure, document and mitigate the impacts of 

stray negative return current. 

Finding R-31 ATC resource challenges potentially 

impact service expansion. 

R-4-31-a WMATA must assess adequacy of Automatic Train Control 

staffing levels resulting from the addition of the Silver Line. 

Finding R-32 WMATA has no formal program for 

reviewing the proficiency of 

maintenance field staff. 

R-4-32-a WMATA must ensure that each department within Transit 

Infrastructure and Engineering Services creates a formal 

program of Supervisory inspections to observe maintenance, 

look at quality of work in the field, and formally intervene to 

evaluate, re-train (if necessary), and enhance the professional 

development of employees. 

Finding R-33 Inventory “stockouts” have impacted 

maintenance operations. Material 

control stock out items are reported 

by Superintendents in Rail Car 

Maintenance, Traction Power and 

Plant as a serious concern in the 

performance of maintenance 

activities and ensuring equipment 

availability, however mitigations 

have not been implemented. 

R-4-33-a Each WMATA Department impacted by inventory stockouts 

must develop a recovery or corrective action plan to ensure 

equipment availability and to manage delays. 

Metrorail Category 5: Fire/Life Safety and Emergency Preparedness 

Finding R-34 Priority maintenance work for 

Fire/Life Safety (FLS) systems and 

other critical infrastructure with 

shared departmental responsibilities 

for inspection and maintenance is 

not completed as required. 

R-5-34-a WMATA must complete its “Fire/Life Safety 1000” maintenance 

procedure, to clarify roles and responsibilities, and outline 

expectations regarding how departments should work together 

to coordinate inspection, maintenance and repair of these 

system components. 

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Final Report – Safety	Management Inspection

Washington Metropolitan Area Transit Authority

WMATA SMI Findings and Required Action Matrix 

Findings by Category Required Action (Safety Directive 15-1)

by Category 

Finding R-35 WMATA must do more to prevent 

and manage conditions that cause 

smoke in tunnels. 

R-5-35-a WMATA must establish clear definitions for infrastructure 

conditions requiring immediate or emergency action, such as 

“arcing insulator.” 

R-5-35-b WMATA must address third rail insulator cleaning and 

replacement requirements and third rail jumper cable 

inspection and replacement requirements as part of the “FLS 

1000” procedure, or in separate but referenced procedures. 

R-5-35-c WMATA must improve its ability to detect the location of smoke 

in its tunnel network. 

R-5-35-d WMATA must resume its program for cable insulation 

resistance testing for its power cables. Insulation resistance 

testing should be performed on power cables every 10 years. 

R-5-35-e WMATA must replace all defective power cables that have 

been identified by traction power inspectors and maintainers. 

R-5-35-f WMATA must set a schedule of drills to assess the 

effectiveness of WMATA’s response to smoke in tunnel and 

station conditions. 

Metrorail Category 6: Condition and Performance of Tunnel Ventilation System 

Finding R-36 Documentation and scheduling of 

tunnel ventilation system 

inspections must be improved to 

ensure compliance with required 

procedures. 

R-6-36-a WMATA must establish a ventilation system testing quality 

audit process to ensure compliance with established 

maintenance and testing practices. 

R-6-36-b WMATA must automate inspection and maintenance record 

keeping for tunnel ventilation systems, drainage pumping 

stations, and other critical systems managed by the Office of 

Plant Maintenance. 

Finding R-37 Newer technology will enhance the 

performance of inspections and 

their quality. 

R-6-37-a WMATA must complete replacement of the pneumatic control 

boxes for ventilation fans with Programmable Logic Control 

systems within the next five years. 

Finding R-38 WMATA’s existing tunnel ventilation 

system was designed and installed 

before modern fire/life safety 

standards were issued for the rail 

transit environment, however, with 

growing passenger loads and eightcar trains, WMATA must look for 

opportunities to improve ventilation 

performance and capacity. 

R-6-38-a WMATA must conduct an engineering assessment to identify 

ways in which to improve the performance and capacity of the 

tunnel ventilation system. 

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Final Report – Safety	Management Inspection

Washington Metropolitan Area Transit Authority

WMATA SMI Findings and Required Action Matrix 

Findings by Category Required Action (Safety Directive 15-1)

by Category 

Metrorail Category 7: Performance of Information Management Technology 

Finding R-39 Difficulties with WMATA’s ELM have 

forced departments to use workarounds resulting in poor 

documentation of initial and 

refresher training, certifications, 

professional licenses and recertifications. 

R-7-39-a WMATA must evaluate the existing Enterprise Learning 

Management recordkeeping system and take corrective action, 

as necessary, to ensure accurate training, re-certification, and 

professional certification records are created, maintained, and 

readily accessible to appropriate managers and employees. 

Finding R-40 WMATA’s MMIS, in its current 

configuration, is cumbersome and 

challenging to use for many 

WMATA maintenance employees. 

R-7-40-a WMATA must develop a training strategy for improving the 

capabilities of employees to enter, analyze and assess 

information into the agency’s Maintenance Management 

Information System. 

R-7-40-b WMATA must establish a data reliability working group focused 

on maintenance information. 

R-7-40-c The Information Technology Department must coordinate with 

the Technical Training Department to ensure the availability of 

additional training on the use of WMATA’s Maintenance 

Management Information System for WMATA’s maintenance 

departments. 

Finding R-41 WMATA’s IT Department lacks 

necessary authority to ensure that 

all WMATA departments use IT 

applications in the same manner to 

ensure data sharing, coordination of 

training, and conduct of audits in a 

consistent manner. 

R-7-41-a WMATA must assess data accessibility and coordination 

needed to support safety functions throughout the agency 

including the operations and maintenance departments. 

R-7-41-b The Information Technology Department must coordinate with 

Rail Operations Quality Training to ensure the availability of 

additional training for the Rail Operations Control Center staff 

on the Advanced Information Management system. 

Finding R-42 Proactive safety analysis of 

information provided by Operating 

and Maintenance departments is 

not routinely conducted. This 

negatively impacts ability of 

WMATA to provide more support for 

proficiency testing, conduct more indepth safety studies, reviews and 

accident/incident investigations. 

R-7-42-a WMATA operating and maintenance departments must work 

together to develop a strategy to more actively analyze, review, 

and assess rail operations and maintenance data from a safety 

perspective. 

R-7-42-b WMATA must work with the Tri-State Oversight Committee and 

FTA to establish and pilot an enhanced investigation process 

for rail transit accidents, incidents and safety studies that 

identify systemic root causes and deficiencies. 

Metrorail Category 8: Outstanding Items from Previous FTA Audits and Reviews 

Finding R-43 Corrective Action Plans from the 

2009 Fort Totten collision remain 

open, including 38 items from the 

System Implementation Gap 

R-8-43-a WMATA must assess the resources assigned to the Automatic 

Train Control Department to ensure their sufficiency to carry 

out critical work, including completion of the program for 

replacement of the Alstom Gen II track circuits by 2017. 

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Final Report – Safety	Management Inspection

Washington Metropolitan Area Transit Authority

WMATA SMI Findings and Required Action Matrix 

Findings by Category Required Action (Safety Directive 15-1)

by Category 

Analysis Report (SIGAR), which 

have not yet been addressed. 

R-8-43-b WMATA must expedite actions to address Corrective Action 

Plans from 2009 Fort Totten collision, including the 38 open 

items from the System Implementation Gap Analysis Report 

(SIGAR). 

R-8-43-c WMATA must replace ATC cables with low insulation 

resistance readings. 

Finding R-44 CWR installation and maintenance 

program changes have not been 

sufficiently evaluated. 

R-8-44-a WMATA must complete required submittals to FTA to close-out 

2012 Safety and Maintenance Audit Recommendation #2 

relating to the WMATA’s rail de-stressing program. 

R-8-44-b WMATA must conduct an independent engineering 

assessment regarding the Critical Rail Neutral Temperature 

and Preferred Rail Laying Temperature Range established in 

“Track Maintenance & Inspection Manual” Revision 6 approved 

on March 16, 2015, to ensure that the likelihood of rail buckles 

is decreased. WMATA’s proposed range (+10 to -19 degrees 

below the preferred rail laying temp of 95) is 9 degrees below 

WMATA’s original measures and does not conform to industry 

standards and recommended practices). 

Metrobus Category 1: Concern over the Protection of Metrobus Operations Personnel 

Finding B-1 WMATA has not addressed 

operator assaults (by passengers) 

at a level commensurate with the 

number of occurrences. 

B-1-1-a WMATA must expedite development of an agency-wide, 

coordinated strategy to address contributing elements to Bus 

Operator Assaults, including training, deployment of police and 

security resources, enhanced community outreach, and 

resolving fare box performance and reliability issues. To the 

extent practical, WMATA should incorporate findings from the 

forthcoming Transit Advisory Safety Committee (TRACS) report 

on this topic. 

B-1-1-b WMATA’s Safety Department must increase its level of 

involvement in the Operator Assault Preventative/Awareness 

Safety Initiative at Local Safety Committees, and in the 

development of the overall strategy for enhanced protection of 

Bus Operators. 

Metrobus Category 2: Limited Availability of Training for Operations and Maintenance Personnel 

Finding B-2 Refresher and other training gaps 

exist within the Transportation and 

Maintenance Departments. 

B-2-2-a WMATA must develop a strategy and approach for developing, 

offering and updating refresher training as required in current 

policies and standards, for key categories of Transportation 

and Maintenance personnel, including Bus Operators, Street 

Supervisors, Bus Operations Control Center Specialists, and 

Bus Maintenance personnel. 

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Final Report – Safety	Management Inspection

Washington Metropolitan Area Transit Authority

WMATA SMI Findings and Required Action Matrix 

Findings by Category Required Action (Safety Directive 15-1)

by Category 

Finding B-3 WMATA does not have a current B-2-3-a WMATA must develop a Bus Operations Control Center 

“BOCC Manual” which lists all office Manual (with processes and procedures for Bus Controller 

procedures and interpretations of Specialists) and a complete set of checklists for implementing 

rules or instructions pertaining to the Standard Operating Procedures and bus vehicle 

BOCC Specialist’s duties. There are troubleshooting guidance. A clear accompanying process 

no checklists available for BOCC should be established for updating the Manual and training 

Specialists to dispatch service or Specialists on its contents and updates. 

manage incidents. 

Metrobus Category 3: Inconsistent Operational Testing and Rules Compliance Checks 

Finding B-4 Bus pre-trip inspections are not B-3-4-a WMATA must assess its overall approach to the performance 

being completed, documented, or of pre-trip inspections to determine the adequacy of time 

monitored to the degree necessary available for Operators to perform these inspections, the level 

to comply with internal WMATA of training available to Operators regarding the conduct of 

SOPs or with industry standards. these inspections, and whether additional condition cards 

should be developed for different sub-fleets. 

Finding B-5 Within WMATA Bus Transportation, 

there are limited formal evaluations 

being conducted of the proficiency 

of Bus Operators. Although there 

are evaluation checklists and 

protocols to measure performance 

and proficiency of WMATA Bus 

Operators, the application of this 

process is not expansive, uniform, 

nor structured within established 

timeframes. 

B-3-5-a WMATA must establish and enforce a formal program to 

ensure that Supervisors assess Bus Operator performance. 

B-3-5-b WMATA must expand the total number and frequency of 

Passenger Service / Operator Skills Audits performed by 

Corporate Quality Assurance. 

Finding B-6 WMATA BOCC Specialists and B-3-6-a WMATA must establish a strategy and timeframe for extending 

SOM/Street Supervisors are the Fatigue Risk Management Program to all Bus Operations 

excluded from WMATA’s fatigue Control Center staff, including BOCC Specialists and the Street 

management program. Operations Managers (SOMs), formerly Street Supervisors. 

Metrobus Category 4: System-wide Maintenance Issues 

Finding B-7 The bus maintenance materials B-4-7-a WMATA must develop and implement a plan to bring its bus 

procurement process is not being maintenance materials procurement process into compliance 

executed in accordance with FTA with FTA Circular 4220.1F. This plan must include a formal 

standards meant to ensure the testing process for newly procured parts and enhancements to 

safety and quality of parts being the process currently used to accept new bus vehicles. 

purchased (FTA Circular 4220.1F). 

Finding B-8 Newly delivered buses have body, 

system, and component problems. 

B-4-8-a WMATA must conduct a resource evaluation regarding overall 

staffing and resources available to Corporate Quality 

Assurance and to other quality divisions and departments 

within Bus Maintenance and Bus Operations to support in-plant 

inspection and general maintenance materials procurement. 

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Final Report – Safety	Management Inspection

Washington Metropolitan Area Transit Authority

WMATA SMI Findings and Required Action Matrix 

Findings by Category Required Action (Safety Directive 15-1)

by Category 

Options to re-instate factory visits must also be considered as 

part of this assessment. 

Metrobus Category 5: Lack of Information Management System Technology 

Finding B-9 Insufficient staffing and tools in 

place for collecting available Bus 

Operations data to support more 

proactive analysis from a safety 

perspective. 

B-5-9-a Conduct an assessment determining the adequacy of 

resources available to support Bus Operations Control Center 

and Bus Superintendents with data entry and analysis. 

Finding B-10 Proactive safety analysis of 

information provided by Operating 

and Maintenance departments is 

not routinely conducted. This 

negatively impacts ability of 

WMATA to provide more support for 

proficiency testing, conduct more indepth safety studies, reviews and 

accident/incident investigations. 

B-5-10-a WMATA must formalize the procedure for how a Local Safety 

Committee will elevate a safety concern to the Departmental 

Safety Committee. 

B-5-10-b WMATA must define the Bus Safety Officer roles and 

responsibilities and conduct an assessment determining the 

adequacy of resources available for Bus Safety Officers to 

complete these responsibilities. 

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Final Report – Safety	Management Inspection

Washington Metropolitan Area Transit Authority

Appendix D: WMATA Organization Chart 

Federal Transit Administration June	17, 2015 116