Track Integrity Investigation
 

Washington Metropolitan Area Transit Authority 

(WMATA)
 

FINAL REPORT
 

Federal Transit Administration 

U.S. Department of Transportation 

1200 New Jersey Avenue, SE 

Washington, DC 20590 

August 8, 2016 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Final Report – Track Integrity Investigation 

Washington Metropolitan Area Transit Authority 

Table of Contents 

1.0 Executive Summary .............................................................................................................. 4
 

2.0 Introduction ........................................................................................................................... 7
 

2.1 Background ..................................................................................................................................... 7
 

2.2 Purpose............................................................................................................................................ 8
 

2.3 FWSO’s Inspection Program .......................................................................................................... 8
 

2.4 Schedule and Major Activities ........................................................................................................ 9
 

2.5 Related Safety Findings and Required Actions .............................................................................. 9
 

2.5.1 Safety Management Inspection ................................................................................................ 9
 

2.5.2 August 6, 2015 Derailment Investigation............................................................................... 11
 

2.5.3 Track Inspection “Safety Blitz” Results................................................................................. 12
 

2.5.4 Immediate Action Letters and Safety Directive 16-3............................................................. 15
 

2.5.5 July 29, 2016 Derailment........................................................................................................ 15
 

2.4.6 WMATA Action..................................................................................................................... 16
 

3.0 Track Inspection and Maintenance ..................................................................................... 17
 

3.1 Track and Structures Department.................................................................................................. 18
 

3.2 Track Inspection............................................................................................................................ 19
 

3.3 Track Maintenance........................................................................................................................ 23
 

4.0 Findings and Required Action............................................................................................. 25
 

4.1 Track Inspection Resources and Training..................................................................................... 25
 

4.1.1 Situation.................................................................................................................................. 25
 

4.1.2 Findings and Required Actions .............................................................................................. 28
 

4.2 TRST 1000 Manual....................................................................................................................... 28
 

4.2.1 Situation.................................................................................................................................. 28
 

4.2.2 Findings and Required Actions .............................................................................................. 30
 

4.3 Track Quality Oversight................................................................................................................ 30
 

4.3.1 Situation.................................................................................................................................. 30
 

4.3.2 Findings and Required Actions .............................................................................................. 32
 

4.4 Track Construction and Maintenance ........................................................................................... 33
 

4.4.1 Situation.................................................................................................................................. 33
 

4.4.2 Findings and Required Actions .............................................................................................. 34
 

Attachment A: Findings and Required Actions Matrix ................................................................ 35
 

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Final Report – Track Integrity Investigation 

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Acronyms 

CADWELD Exothermic welding process named for Dr. Charles Cadwell 

CAP Corrective Action Plan 

CENI WMATA Office of Chief Engineering, Infrastructure 

CMNT WMATA Office of Rail Car Maintenance 

CPDO WMATA Office of Capital Program Delivery 

DF Direct Fixation 

DOT United States Department of Transportation 

FTA Federal Transit Administration 

FWSO FTA WMATA Safety Oversight 

MMIS Maintenance Management Information System 

MSRPH Metrorail Safety Rules and Procedures Handbook 

OAP Operations Administrative Procedures 

POWR WMATA Power Branch within Office of Systems Maintenance 

QAAW WMATA Office of Quality Assurance and Warranty 

QICO WMATA Quality and Internal Compliance Office 

ROCC Rail Operations Control Center 

RTRA WMATA Office of Rail Transportation 

RWIC Roadway Worker in Charge 

RWP Roadway Worker Protection 

SAFE WMATA Department of Safety and Environmental Management 

SMI Safety Management Inspection 

SMNT WMATA Office of System Maintenance 

SOP Standard Operating Procedure 

SSO State Safety Oversight 

TIES WMATA Department of Transit Infrastructure and Engineering Services 

TOC Tri-State Oversight Committee 

TRST WMATA Office of Transit and Structures 

WMATA Washington Metropolitan Area Transit Authority 

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Final Report – Track Integrity Investigation 

Washington Metropolitan Area Transit Authority 

1.0 Executive Summary 

This report documents 12 findings from an investigation conducted by the Federal Transit 

Administration (FTA) Washington Metropolitan Area Transit Authority (WMATA) Safety 

Oversight (FWSO) team from March through June 2016 into the integrity of the Metrorail track 

system. These findings are reinforced by the FTA’s preliminary determination of probable cause 

regarding the July 29, 2016, derailment near the East Falls Church Station, which indicates 

systemic safety deficiencies in the inspection, maintenance and repair of track. This report also 

describes 12 required actions WMATA must take to address the FWSO’s findings. These 

requirements will be formally issued to WMATA separately through FTA Safety Directive 16-4. 

Since FTA assumed temporary safety oversight of Metrorail in October 2015, WMATA has 

taken of number of critical steps to address safety deficiencies, but significant additional work 

remains to be done. The FTA supports these efforts and will continue to serve in an oversight 

role until the State of Maryland, the Commonwealth of Virginia and the District of Columbia 

stand up a new SSOA that meets the requirements of Federal law. The FTA, utilizing resources 

from across the U.S. Department of Transportation (DOT), carries out its safety oversight 

function by conducting inspections and investigations and directing WMATA to address 

deficiencies in a timely, adequate and systematic manner.1 

The FWSO’s track integrity investigation focused on 1) the adequacy of WMATA’s track 

inspection process and resources, 2) the quality of WMATA’s track standards, 3) the quality of 

training for track inspectors and maintainers, and 4) specific track maintenance and construction 

quality program issues. 

The FWSO initiated this investigation in response to concerns stemming from: 

•	 FWSO’s review of WMATA’s investigation into a major derailment that occurred on 

August 6, 2015, near Smithsonian Station; 

•	 Several FWSO track inspections conducted in late February and early March 2016; 

•	 FWSO’s investigation into the March 14, 2016 arcing insulator fire at McPherson Square, 

including all 27 track locations where WMATA made emergency repairs during its selfimposed March 16, 2016 system-wide shut down; and 

•	 Follow-up activity with WMATA to verify actions completed to address findings from 

FTA’s Safety Management Inspection (SMI) and Safety Directive 15-1. 

The FWSO focused its investigation on 10 specific track segments, including part of all six 

Metrorail lines, comprising over 60 miles of WMATA track in tunnels, at-grade, and on aerial 

structures. The majority of the FWSO’s investigation activity took place between March 21 and 

April 15, 2016, with targeted follow-up field inspections taking place between April 28 and June 

1 FTA manages and coordinates the use of DOT-wide resources to ensure effective safety oversight of WMATA 

Metrorail. The DOT-wide team is referred to as the FTA WMATA Safety Oversight Team (FWSO). 

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Final Report – Track Integrity Investigation 

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30, 2016 on the Red Line and sections of the Orange/Blue/Silver Line, where WMATA 

completed urgent repairs to address initial FWSO findings. Results from FWSO inspections 

conducted at various SafeTrack locations since June 4, 2016, and findings from the Tri-State 

Oversight Committee (TOC) three-year review on track maintenance and training, have also 

been incorporated into this investigation. 

As detailed in this report, the FWSO found that WMATA’s track inspection program does not 

provide sufficient time for inspectors to adequately inspect their assigned territories, and does not 

fully account for differences in track types, locations, and the volume of train traffic. Also, the 

FWSO determined that WMATA does not prioritize the inspection importance of tracks, and that 

maintenance departments do not jointly review issues and safety concerns affecting the track 

structure to develop coordinated mitigations and assign limited resources to highest priority 

issues. 

The FWSO also determined that WMATA’s existing Track and Structures Inspection and 

Maintenance Manual (TRST 1000) contains outdated references, confusing and conflicting 

information on track standards and requirements, and does not clearly specify minimum safety 

standards. As a consequence, the procedure for WMATA track inspectors and supervisors to use 

the Manual to assess track conditions and clearly identify which conditions warrant speed 

restrictions is not well understood by track inspectors or track supervisors. Furthermore, the 

FWSO determined that WMATA’s track inspectors require additional technical training and 

mentoring to overcome gaps in knowledge and experience. 

The FWSO also identified track maintenance and construction quality issues, including the 

incorrect installation of anchor bolts on WMATA’s direct fixation track fastening system to 

secure tracks on aerial structures and in tunnels. Also, the FWSO verified that much of the 

drainage system in WMATA’s tunnel structure is not maintained in a state of good repair. Given 

the corrosive and deleterious effects of water on track and traction power infrastructure, FWSO 

found that drain maintenance should be a much higher priority in WMATA’s overall track 

inspection and maintenance program. Finally, FWSO found that WMATA’s Track Geometry 

Vehicle (TGV) could provide greater support to its overall track inspection program. 

During the course of this investigation, track safety incidents continued to occur, notably arcing 

insulator events at Friendship Heights Station on April 27, 2016 and at Federal Center SW 

Station on May 5, 2016. As a result, the FWSO issued to WMATA two Immediate Action 

letters and Safety Directive 16-3 to focus WMATA activity on urgent improvements needed to 

enhance fire and life safety in the tunnels, to clarify the rules and protections afforded to workers 

on the right-of-way, to manage water intrusion and deficient track conditions in three specific 

locations, to enhance emergency preparedness and response to events in tunnels, and to ensure 

that safety is prioritized over operations when making decisions that affect passengers and 

employees. 

Although WMATA is making progress, and has addressed many of the FWSO’s immediate 

actions communicated in recent letters and Safety Directive 16-3, as discussed in this report, 

concerns remain regarding the quality of WMATA’s track inspection and maintenance program. 

On July 29, 2016, a Metrorail passenger train derailed at a crossover outside of East Falls Church 

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Station. While the investigation is on-going, visual inspection conducted by the FWSO as part of 

the derailment investigation confirmed poor crosstie condition, loose and missing fasteners, and 

evidence of excessive lateral rail movement and wide gauge. These conditions clearly exceeded 

allowable safety parameters specified in WMATA’s track safety standards, and were not found 

or addressed by WMATA personnel prior to the derailment. There is also evidence that 

WMATA was not adhering to established standards regarding the frequency of track inspections. 

Notably, preliminary findings from the FWSO’s investigation of the July 29th derailment are 

consistent with the FWSO findings set out in this report. Moreover, during the track integrity 

investigation, the FWSO highlighted concerns regarding the overall track conditions on the 

section of K-Line track from Vienna to Ballston, as crossties and other track components are 

reaching the end of their useful life. FWSO encouraged WMATA to include this track in its 

SafeTrack program, and specifically to prioritize work between East Falls Church to Ballston, as 

one of the first three SafeTrack surges. The particular interlocking involved in the derailment 

was not part of this initial surge because it was used to support single tracking operations. The 

interlocking at issue was originally scheduled for renewal later in the SafeTrack program, but, as 

a result of the derailment, WMATA completed renewal activities on August 1, 2016. 

Also, in response to this derailment, WMATA has committed to performing detailed, 

supervisory pre-inspections of all turnouts, switches and crossovers required to be used to 

facilitate SafeTrack closures and single tracking operations. WMATA also will start an 

immediate special supervisory inspection of all crossovers on mainline tracks, including quality 

audits. The FTA expects WMATA to continue these actions through the remainder of the 

SafeTrack program, and will be monitoring the performance and quality of these inspections. 

As directed by Safety Directive 16-4, WMATA must develop corrective action plans to address 

the findings of this report and related required actions. The FWSO will review and approve 

WMATA’s work plans, and will monitor the agency’s progress toward implementing the safety 

improvements. Additionally, the FWSO will work with WMATA to review and revise all preexisting corrective action plans (CAPs), including CAPs related to track integrity, as appropriate 

to ensure that WMATA continues to make timely progress towards returning Metrorail to a good 

state of repair. 

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Final Report – Track Integrity Investigation 

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2.0 Introduction 

This report documents the results of the track integrity investigation conducted by the Federal 

Transit Administration (FTA) between March 21 and June 30, 2016 on the Washington 

Metropolitan Area Transit Authority (WMATA) Metrorail system. The FTA WMATA Safety 

Oversight (FWSO) Office initiated this investigation in response to recurrent track deficiencies 

and defects identified during FWSO’s track inspections at WMATA, and to support follow-up on 

track issues identified as part of the FWSO’s Safety Management Inspection (SMI). The FWSO 

also used this investigation to explore systemic issues identified as part of WMATA’s 

investigation into a derailment near Smithsonian Station on August 6, 2015 and Tri-State 

Oversight Committee (TOC) three-year review into track maintenance and training at WMATA.. 

Finally, this report also addresses preliminary findings from the FWSO’s investigation into the 

July 29, 2016 derailment near East Falls Church. 

2.1 Background 

The WMATA Metrorail system is the second largest rail transit system in the United States with 

269.8 total track miles, including 136.6 miles at grade, 18.4 miles on elevated structures, .5 miles 

elevated on fill, 3.1 miles open-cut tunnel, and 111.2 miles of subway tunnels.2 WMATA’s track 

infrastructure includes track bed structure (sub-base, tunnel inverts, bridges, or other substructures), running rails, ties and ballast or direct fixation system, fasteners, special trackwork, 

such as switches and turnouts, drainage system elements, traction power contact “third” rail, 

traction power feeder cables, conduits, manholes and potheads. Impedance bonds are also 

located in the track bed and connected to the running rails. 

WMATA manages the integrity of this critical infrastructure through a series of inspection, 

testing and maintenance standards and programs, renewal programs, and engineering 

assessments and modifications. Within WMATA’s Transit Infrastructure and Engineering 

Services (TIES) Department, Track and Structures (TRST) is responsible for track inspection, 

maintenance, and production, including the track bed, running rails and third rail, and supporting 

infrastructure. Within System Maintenance (SMNT), the Power (POWR) Branch and the 

Automatic Train Control (ATC) Branch maintain key elements of the positive and negative 

return systems, respectively, for the traction power system. The Capital Project Development 

Office (CPDO) is responsible for the testing, replacement, and upgrade of traction power cables 

and other traction power system elements, and, recently also initiated a traction cable inspection 

program. The Office of Chief Engineering, Infrastructure (CENI) provides critical engineering 

services to support each department in managing engineering modifications and site assessments, 

upgrades, and addressing changing infrastructure conditions. CENI, in coordination with TRST, 

also manages the TGV program. 

WMATA’s maintenance, engineering and capital project departments and branches have adopted 

safety standards and manuals, engineering procedures, and an approach to issuing work 

instructions and site-specific drawings to govern most activities performed to ensure the integrity 

of the track and traction power system. WMATA provided the FWSO with copies of these 

2 As reported by WMATA to the National Transit Database (NTD).

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Final Report – Track Integrity Investigation 

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materials, and supported multiple meetings with FWSO’s experts to review specific requirements 

and practices and to clarify WMATA’s unique conventions and classification systems. 

2.2 Purpose 

This investigation report focuses on: 1) the adequacy of WMATA’s track inspection process and 

resources, 2) the quality of WMATA’s track standards, 3) the quality of training for track 

inspectors and maintainers, and 4) specific track maintenance and construction quality program 

issues. This investigation report does not contain itemized inspection findings relating to 

specific track defects but rather addresses systemic issues limiting the effectiveness of 

WMATA’s track inspection and maintenance program. This report builds on other findings 

issued to WMATA in recent FWSO communications, including the April 18 and May 11 

Immediate Action letters and Safety Directive 16-3, regarding track system inspection and 

maintenance. The FWSO’s previous communication on these issues is available at: 

•	 April 18, 2016 Letter, Immediate Actions to Address Fire/Life Safety and the Protection 

of Workers on the Right-of-Way, https://www.transit.dot.gov/regulations-andguidance/safety/fta-letter-wmata-track-safety-blitz-immediate-actions-april-18-2016. 

•	 May 11, 2016 Letter, Urgent Repairs Required Prior to Start-up of SafeTrack Plan, 

https://www.transit.dot.gov/regulations-and-guidance/safety/fta-letter-wmata-urgentrepairs-required-prior-start-wmata-safe. 

•	 Safety Directive 16-3 Required Actions to Address Persistent Critical Open Safety 

Findings Issued to WMATA (May 7, 2016), https://www.transit.dot.gov/regulations-andguidance/safety/fta-safety-directive-16-3. 

•	 Letter from FTA Acting Administrator WMATA General Manager re: FTA Safety 

Directive 16-3 (May 18, 2016), https://www.transit.dot.gov/regulations-andguidance/safety/wmata-response-fta-safety-directive-16-3. 

2.3 FWSO’s Inspection Program 

While this investigation report focuses on systemwide issues, the FWSO shares all deficient 

track conditions identified during FWSO’s track inspections with WMATA in formal inspection 

reports, typically transmitted to WMATA within 3 days of the inspection. In addition, the 

FWSO’s inspectors telephone and email WMATA supervisors and leadership regarding the 

identification any serious items requiring priority action. Also, since WMATA track supervisors 

typically accompany FWSO’s inspectors, defective conditions identified by the FWSO’s 

inspectors are often called in for corrective maintenance immediately from the track wayside. 

Through the course of these inspections, since December 2015, the FWSO has issued over 600 

remedial actions to WMATA to correct deficient track conditions. While FWSO has verified 

closure of approximately 20 percent of these remedial actions through re-inspection, the FWSO 

and WMATA are currently establishing a system to reconcile maintenance work orders with 

FWSO remedial actions, so WMATA can report on the closure of remedial actions monthly. The 

FWSO anticipates that this system will be in place by the end of September. (The FWSO will not 

close open remedial items issued to WMATA unless verified through a completed WMATA 

work order or re-inspection in the field.) In the interim, to the extent possible, the FWSO 

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continues to monitor WMATA action to address identified track defects through follow-up reinspections and review of work order scheduling in WMATA’s maintenance database. 

2.4 Schedule and Major Activities 

The FWSO formally notified WMATA regarding the decision to conduct an investigation into 

track integrity issues in early March. The FWSO then worked closely with WMATA to complete 

a document request and to schedule interviews, field observations, inspections, and 

demonstrations regarding the condition of the track and traction power infrastructure and the 

performance of key equipment, information management systems, technology, and personnel. 

The majority of the FWSO’s investigation activity took place between March 21 and April 15, 

2016, with targeted follow-up field inspections taking place between April 28 and June 30, 2016 

on the Red Line and sections of the Orange/Blue/Silver Line, where WMATA completed urgent 

repairs to address initial FWSO findings. In addition, largely in response to concerns with track 

quality identified by the FWSO and WMATA in March and April, WMATA expedited its 

SafeTrack program to prioritize efforts to complete critical maintenance and rehabilitation of its 

track system. Since June 4, 2016, FWSO personnel have conducted multiple inspections of each 

SafeTrack surge location to verify the completion and quality of prioritized work. 

WMATA participated in two agency-wide meetings to discuss FTA’s findings in April and May, 

and completed a factual review of this report in July. 

2.5 Related Safety Findings and Required Actions 

Over the last year, the FWSO has issued a number of findings and required actions to WMATA 

regarding track and traction power inspection and maintenance issues. This report acknowledges 

these previous findings and the status of WMATA’s implementation of approved corrective 

action plans in addressing them. 

2.5.1 Safety Management Inspection

During the 2015 SMI, the FWSO evaluated the WMATA Metrorail system’s maintenance and 

inspection programs for critical infrastructure, including track and traction power systems. The 

FWSO also completed a general assessment of track and third rail conditions at locations 

throughout the system. 

On June 17, 2015, as part of Safety Directive 15-1, the FWSO issued several required actions for 

improvements to these programs and the condition of this infrastructure, directing WMATA to 

ensure that maintenance and inspection crews have sufficient access to the track to complete 

their work and that the work is adequately supervised, that inspector and maintainer training and 

quality programs are improved, and that enhancements are made to WMATA’s roadway worker 

protection (RWP) program. WMATA has corrective action underway to address the following 

required actions: 

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Final Report – Track Integrity Investigation 

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•	 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. (Status: Work underway, due December 2017.) 

•	 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. (Status: 

Submitted to FWSO for closure; FWSO is requesting additional action.) 

•	 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, retrain (if necessary), and enhance the professional development of employees. (Status: 

Closure request under FWSO review.) 

•	 R-7-42-a: WMATA operating and maintenance departments must work together to 

develop a strategy to more actively analyze, review, and assess rail operation and 

maintenance data from a safety perspective. (Status: Work underway, due March 2018.) 

•	 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. (Status: Work underway, due August 2017.) 

•	 R-2-16-d: WMATA must establish formal guidance for maintenance employees 

responsible for providing on-the-job training. (Status: Submitted to FWSO for closure; 

FWSO is requesting additional action.) 

•	 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. 

(Status: Submitted to FWSO for closure; FWSO is requesting additional action.) 

•	 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. (Status: 

Submitted to FWSO for closure; FWSO is requesting additional action.) 

•	 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. (Status: Submitted to FWSO for 

closure; FWSO is requesting additional action.) 

•	 R-3-26-a: WMATA must improve interdepartmental coordination and communication to 

take full advantage of track time. (Status: Submitted to FWSO for closure; FWSO is 

requesting additional action.) 

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Final Report – Track Integrity Investigation 

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•	 R-8-44-a: WMATA must complete required submittals to FWSO to close-out 2012 

Safety and Maintenance Audit Recommendation #2 relating to WMATA's rail destressing program. (Status: Submitted to FWSO for closure; FWSO is requesting 

additional action.) 

•	 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. (Status: Submitted to FWSO for closure; FWSO is requesting 

additional action.) 

2.5.2 August 6, 2015 Derailment Investigation

Two months before FTA (through its FWSO) assumed temporary safety oversight responsibility 

for Metrorail, WMATA Train #412 derailed on the D-line at Curve 306 near Smithsonian 

Station. While there were no injuries as a result of this incident, the derailment caused damage 

to multiple components of the track and trackbed, including track, rail fasteners, clips and bolts, 

ATC and power equipment. The derailment also damaged rail car wheels and trucks, forcing the 

suspension of service on the Orange/Blue/Silver Lines for most of the day. 

In its direct, temporary safety oversight capacity of WMATA (in accordance with Safety 

Directive 16-1), the FWSO initiated a review of WMATA’s investigation findings and corrective 

action plans. Concurrent with its review of this draft report, FTA conducted track inspection 

verification activities at WMATA in November and December 2015, and reviewed the triennial 

track maintenance audit issued by the TOC in December 2015. The FTA and TOC conducted 

several meetings regarding this derailment, and the condition of WMATA’s track infrastructure 

in general. The FTA also reviewed the remedial actions taken by the TRST in response to this 

accident, and the status of the track-related corrective action plans developed by WMATA in 

response to the FTA’s SMI. 

On February 16, 2016, the FTA requested additional action from WMATA to complete this 

investigation. WMATA responded to FTA on March 16, 2016, and elements of this response 

were also discussed during the FTA’s subsequent track integrity investigation. WMATA 

identified the following root causes of the August 6, 2015 derailment: 

1.	 Failure of WMATA’s TIES and TRST leadership to manage the TRST trackwalker 

inspection and corrective maintenance processes effectively; and 

2.	 Failure of management to manage the TRST TGV track inspection and corrective 

maintenance program and processes effectively. The deficiencies in the TRST track 

walker and TGV track inspection and corrective maintenance program and processes 

encompass the following: 

a.	 Ineffective management by TRST of data gathered from the field as well as 

failure to properly schedule and prioritize maintenance with this information, 

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Final Report – Track Integrity Investigation 

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b.	 The lack of an approved procedure for the TGV inspection program and process, 

as required by Section 12.3.3 of the System Safety Program Plan, and 

c.	 Ineffective management and oversight of maintenance management training, 

procedures and policy. 

In response to the FWSO’s request, WMATA revised the report to include additional 

information on the underlying metallurgical, track construction, and maintenance quality issues 

that contributed to the deficient track conditions. WMATA also provided additional information 

on potential deficiencies in the training, qualification and certification of track inspectors. Also, 

WMATA clarified actions underway to determine the exact number of preventive maintenance 

work orders completed by the Track Maintenance Branch, and the apparent conclusion, provided 

on Page 20 of the draft report, that preventive maintenance programs “are on the back burner.” 

Finally, WMATA initiated a series of assessments regarding track quality and condition which 

ultimately resulted in the SafeTrack program, and also initiated a series of reviews by contractors 

and peers to identify opportunities to improve track inspection procedures, training, and data 

quality. 

2.5.3 Track Inspection “Safety Blitz” Results

Between March 21 and April 15, 2016, seven (7) teams, comprised of DOT inspectors, track and 

traction power engineers, and track and traction power subject matter specialists, inspected over 

60 miles of WMATA track, including running rails, contact rails, insulators, cables and 

assemblies, track beds, ties, fasteners, fixation systems, switches, turnouts, crossovers, and all 27 

locations where WMATA made repairs to its traction cable power electrification system on 

March 16, 2016. 

FWSO’s teams also reviewed maintenance records and work orders, engineering specifications, 

and observed roadway worker safety training and corrective maintenance work performed during 

WMATA's OWL shift. Finally, FWSO’s teams evaluated training materials and programs for 

WMATA’s track inspectors, track maintainers, and traction power technicians. 

While FWSO’s teams found that track conditions in many locations generally conformed to 

WMATA’s track safety standards, out-of-compliance conditions were also identified, including 

rows of missing fasteners and defective ties, rail corrosion, and missing bolts and excessive wear 

in switches and crossovers. In all, over three weeks between March 21 and April 15, 2016, 

FWSO’s inspection teams identified almost 400 defects in track conditions, including 7 “black" 

conditions in three locations that required WMATA to take track out of service and 7 additional 

"red" conditions that required WMATA to impose speed restrictions. 

Examples of typical defects found by FWSO’s teams that require repair include the following: 

•	 Missing direct fixation fasteners, 

•	 Rail surface spalling, 

•	 Missing and defective ties, 

•	 Rail corrosion, 

•	 One cracked third rail, 

•	 Broken third rail support brackets, 

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• Loose switch rod bolts, 

• Missing track fasteners and clip clusters, 

• Rail shelling, 

• Standing water and blocked drains within the gauge of the track, 

• Fastener defects in standing water, 

• Joint clip defects, 

• Rail and other debris stowed on safety walks, 

• Missing third rail cover boards, 

• Lights not working at Emergency Telephone Stations, 

• Exposed wires at impedance bonds, 

• Broken studs, missing stud nuts, and cracked grout pads, 

• Broken frog fasteners, and 

• Tunnel lighting defects. 

At many locations, FWSO’s teams found the irregular or inappropriate installation of stud bolts 

designed to anchor the direct fixation system. FWSO also noted violations of fire/life safety 

standards related to expired fire extinguishers, blocked safety exists and catwalks, obscured or 

missing safety signage, inadequate tunnel lighting, non-functioning Emergency Trip Station 

(ETS) boxes, and missing or poorly stocked emergency boxes for switch repair. 

During the course of its investigation, FWSO also re-inspected previous defects identified to 

assess repairs. The FWSO found that two defects (3rd rail joint at Mt. Vernon and tread wear on 

frog in Fort Totten interlocking) had been repaired in conformance with WMATA track 

standards. However, the FWSO also noted a defective drainage condition at the location near Mt. 

Vernon Station. This condition had not been corrected at the time of the FWSO re-inspection, 

and was the ultimate root cause of the defective gauge measurement. 

Throughout the course of the investigation, FWSO also identified four direct fixation (DF) 

fastener defects that included more than the 120 inch maximum distance allowed between 

effective fasteners. According to WMATA maintenance standards anything over 120 inches 

requires that a “black” (out of service) condition be placed on the track. However, WMATA 

track supervisors at the location with FWSO’s team determined that 15 mph speed restrictions 

would be sufficient for two of these three conditions. WMATA did remove from service the 

track with the third instance of missing fasteners. This short section of track in the crossover 

between two switches measured 456 inches (over 21 feet) between effective fasteners. This is 

almost four times the minimum allowed by WMATA’s maintenance standards. WMATA 

requires a twice weekly mainline walking inspections and monthly switch inspections. In the 

course of one month, this area would have been inspected, at a minimum, nine times, yet this 

condition was not identified or addressed. 

During the last week of March and the first week of April, FWSO’s teams also inspected all 27 

locations where emergency repairs were made to traction power cables as a result of WMATA's 

March 16, 2016 emergency shutdown. FWSO inspections of traction power cable repairs 

generally found that the repairs made on March 16, 2016 were made in conformance with 

WMATA engineering specifications, and infrared temperature monitoring of the cables and 

connections did not indicate any large swings from ambient temperature. The FWSO did identify 

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two locations were additional engineering evaluation was warranted, and also reported four other 

cable conditions to WMATA for repair. 

Most significantly, FWSO found multiple water leaks between the Potomac Avenue and 

Stadium-Armory stations, including a gushing leak at the safety catwalk and a smaller leak just 

above a newly installed boot and a cable. Additionally, between McPherson Square and Farragut 

West, and Stadium-Armory and L'Enfant Plaza, FWSO discovered damaged or completely cut 

C-bonds at running rail joints. Specific findings identified and reported to WMATA include: 

•	 Cable connectors on the slab at crossover kicker rails where adjustments must be made 

and/or support provided beneath the cable/termination to separate the termination from 

the concrete. 

•	 Cables laying on concrete slab, where WMATA could potentially install cable standoffs 

with insulators to separate cable from concrete. 

•	 Duct line transition from concrete slab was not always protecting the cable – some areas 

used heat shrink tubing, link seal or OZ Gedney bushings. 

•	 Several third rail anchors were under stress or broken. 

•	 Cover boards missing. 

•	 Debris and trash embedded in track beds near end approaches potentially within reach of 

sparks from collector shoes. 

•	 Insulator contamination. 

•	 Expansion joint inspection showed that replacement cable in several locations is under 

stress and lacked drip loop configuration. 

•	 In the area of the two kicker rails, third rail cable potheads were observed to be laying 

directly on the ground. 

•	 Unusual wear patterns and multiple knocked off collector shoes were noted at the end 

approach near the Farragut West station platform. 

•	 Signs of electrical arcing on tunnel wall between Federal Center and Capitol South. 

FWSO's team also found a third rail tensioner under stress, and an additional location with 

expansion joint cables with slashed insulation where cables are lying on the ground with some tie 

plates on them. The FWSO has since initiated a separate special investigation, and will be 

issuing a separate investigation report on WMATA’s traction power electrification system. 

Finally, through the course of this inspection activity, FWSO observed numerous violations of 

WMATA’s RWP program. FWSO’s teams found that train operators did not consistently follow 

speed restrictions verbally conveyed over the radio. As noted in the FWSO’s SMI, formal repeatbacks are not always required, and FWSO’s teams experienced instances where trains passed 

locations with newly imposed speed restrictions at greater than 15 miles per hour. 

As explained in Section 2.3 above, all inspections conducted to support this investigation 

resulted in formal inspection reports that were provided to WMATA. Inspection reports are 

uploaded to a shared folder, and also emailed to key leadership in WMATA’s track and safety 

departments. Major safety concerns are communicated immediately. The FWSO also conducts a 

verbal briefing with WMATA staff at the conclusion of each inspection. Specifically for the 

track integrity investigation, the FWSO also conducted two meetings with WMATA’s senior 

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management and technical leadership, on April 11 and May 19, 2016, to review major findings, 

issues and concerns, and to discuss and verify the development of WMATA’s track quality 

improvement program and the new SafeTrack program, as well as steps that WMATA is taking 

to improve its track inspection and maintenance program. 

2.5.4 Immediate Action Letters and Safety Directive 16-3

Based on the results of this investigation, and a set of additional arcing insulator events occurring 

at Friendship Heights Station on April 27, 2016 and at Federal Center SW Station on May 5, 

2016, the FTA issued two (2) Immediate Action letters, on April 18 and May 11, 2016, 

respectively, and Safety Directive 16-3: Required Actions to Address Persistent Critical Safety 

Concerns on May 7, 2016. Through this communication, FWSO focused WMATA attention on 

urgent needed improvements required to enhance fire/life safety in the tunnels, to clarify the 

rules and protections afforded to workers on the right-of-way, to manage water intrusion and 

deficient track conditions in three specific locations, to enhance emergency preparedness and 

response to events in tunnels, and to ensure that safety is prioritized over operations when 

making decisions that affect passengers and employees. 

Over the last two months, the FWSO and WMATA have worked through many of these issues 

and concerns, particularly regarding fire/life safety equipment and features in tunnels, and the 

need to reinforce RWP rules compliance. The FWSO verified that WMATA has completed 

several of the required actions, and continues to monitor WMATA’s responses to Safety 

Directive 16-3, and the immediate action letters, including the prioritization of specific locations 

and repairs identified by the FWSO in WMATA’s SafeTrack program and WMATA’s on-going 

commitment to prioritize safety over service in managing response to specific track and traction 

power incidents and related service disruptions. 

2.5.5 July 29, 2016 Derailment

On July 29, 2016, a Metrorail passenger train derailed at a crossover outside of East Falls Church 

Station. While the investigation is on-going, visual inspection conducted by FWSO as part of the 

derailment investigation confirmed poor crosstie condition, loose and missing fasteners, and 

evidence of excessive lateral rail movement and wide gauge. These conditions clearly exceeded 

allowable safety parameters specified in WMATA’s track safety standards, and were not found 

or addressed by WMATA personnel prior to the derailment. There is also evidence that 

WMATA was not adhering to established standards regarding the frequency of track inspections. 

Failure to comply with these standards may have contributed to the derailment. 

Notably, preliminary findings from FWSO’s investigation of the July 29th derailment are 

consistent with the FWSO findings set out in this report. Moreover, during the track integrity 

investigation, FWSO highlighted concerns regarding the overall track conditions on the section 

of Orange/Silver Line track from Vienna to Ballston, as crossties and other track components 

reach the end of their useful life. FWSO encouraged WMATA to include this track in its 

SafeTrack program, and specifically to prioritize work between East Falls Church to Ballston, as 

one of the first three SafeTrack surges. The particular interlocking involved in the derailment 

was not part of this initial surge because it was used to support single tracking operations. The 

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interlocking at issue was originally scheduled for renewal later in the SafeTrack program, but, as 

a result of the derailment, WMATA completed renewal activities on August 1, 2016. 

In the immediate aftermath of the derailment, WMATA issued a preliminary report of 

investigation. According to the preliminary report, “the causal factor in this event is that track 

ties at the [Point of Derailment] were deteriorated to the point where they were no longer 

effective in restraining the dynamic lateral forces transferred to the track by train 602.” 

Working with WMATA and the FTA, the National Transportation Safety Board (NTSB) 

conducted a limited investigation of this derailment, and in the briefing they provided to 

Congressional staff for members of Congress from the region, as well as committee staff with 

oversight for transportation safety, the NTSB did not state probable cause, but did convey 

findings of fact regarding the extent of wide gauge at the location of the derailment and the 

presence of a severe defective tie condition in the derailment area. 

In response to this derailment, WMATA has committed to performing detailed, supervisory preinspections of all turnouts, switches and crossovers required to be used to facilitate SafeTrack 

closures and single tracking operations. WMATA also will start an immediate special 

supervisory inspection of all crossovers on mainline tracks. Finally, WMATA will perform 

quality audits of both SafeTrack and mainline supervisory inspections. The FTA expects 

WMATA to continue these actions through the remainder of the SafeTrack program, and will be 

monitoring the performance and quality of these inspections. 

2.4.6 WMATA Action

In response to the August 5, 2015 derailment, the findings of the FWSO’s SMI, and WMATA’s 

ongoing analysis regarding the condition of its infrastructure, the FWSO finds that WMATA is 

taking many actions to improve the quality of its track inspection and maintenance programs. 

WMATA has established the SafeTrack program to address some of its most track significant 

maintenance backlog. WMATA is also proposing a new service schedule to accommodate 

additional time to address track maintenance requirements. 

WMATA is in the process of conducting several external reviews, by contractors and the 

American Public Transportation Association (APTA), to assess the resources and requirements 

for its track and structures maintenance program. WMATA is overhauling its track safety 

standards and its track inspection training, and is working with another contractor to conduct a 

systemwide track inspection and to overhaul and correct the defect entries in WMATA’s 

Maintenance Management Information System (MMIS) database. WMATA also is expanding its 

TGV program and training. The FWSO hopes that the findings and required actions outlined in 

this report will assist WMATA in focusing its attention on safety-critical priorities as it develops 

and implements new programs to enhance its track inspection and maintenance programs. 

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3.0 Track Inspection and Maintenance 

At WMATA, direct fixation track is the standard method of construction for tracks on aerial 

structures and in tunnels. Direct fixation track is a “ballastless” track structure in which the rail 

is mounted on direct fixation fasteners that are attached to a concrete deck, slab, or invert. 

Ballasted track is used for most at-grade and yard locations. 

The map below depicts the usage of the WMATA track system in terms of million gross tons per 

year. The track segments with thicker, redder lines experience the greatest volume of train traffic 

with the most weight. The Rosslyn to D98 corridor, the most used track segment, with all 6-car 

train operation, annually manages 37 million gross tons in trains and passenger weight. When 

WMATA moves to 100 percent 8-car train operations, using the new 7000 series vehicles, this 

segment will manage up to 55 million annual gross tons. This segment also requires the greatest 

level of attention in terms of track inspection and maintenance. 

Figure 1: WMATA Track Usage Visualization 

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3.1 Track and Structures Department 

TRST is responsible for track inspection, maintenance, and production on the WMATA system. 

The following policies and procedures govern all track work: 

•	 TRST1000 – Track Maintenance and Inspection Manual. Revision 6. January 1, 2015. 

•	 TRST 2000 – Track and Structures Maintenance Control Policy. Revision 6. February 20, 

2015. 

•	 Metrorail Safety Rules and Procedures Handbook. April 9, 2015 (Electronic Update). 

•	 Operations Administrative Procedure 208-01. Track Maintenance Management, 

Maintenance of Way. July 31, 2006. 

•	 Operations Administrative Procedure 208-02. Structures Maintenance Management, 

Maintenance of Way. July 31, 2006. 

•	 Roadway Worker Protection Manual. June 2014. 

Within TRST, the Track Inspection Branch (TKIN) has responsibility for inspecting WMATA 

tracks and supporting infrastructure for defects. Rail transit agencies must inspect tracks to detect 

defects, monitor defect progression, and take corrective action when required to ensure the safety 

of employees and passenger operations. There are two types of track inspection: (1) visual 

inspection performed by inspectors generally on foot but sometimes by train or high-rail vehicle 

at slow speeds, and (2) automated track inspection, performed by a vehicle or piece of equipment 

using ultrasonic or electromagnetic methods. Many large rail transit agencies, such as WMATA, 

combine the two types of inspection, with visual inspection used as the primary, day-to-day 

means for ensuring the safe condition of the track, and automated inspection supporting the 

identification of difficult-to-detect defects and providing an annual or semi-annual assessment of 

overall track integrity by line or section. 

At WMATA, track inspections, accomplished on foot daily, provide the primary method for 

observing and recording deterioration that could adversely affect Metrorail operations. 

WMATA’s TRST 1000 Manual requires TKIN to performs the following walking inspections: 

•	 Visual mainline track inspections twice weekly. 

•	 All mainline switches, turnouts and special trackwork, no less than monthly. 

•	 All yard and yard switches, monthly. 

TKIN also coordinates, but does not manage, automated inspections i.e., rail flaw, lateral load, 

geometry, ultrasonic and component assessment with the Chief Infrastructure Engineer (CENI) 

and vendors. Using the TGV, ultrasonic rail inspection is performed a minimum of twice a year 

and automated track geometry inspection, rail surface condition inspection and rail wear 

condition inspection are performed four times per year for the entire system. WMATA is still 

finalizing its approach to incorporating the TGV into its overall inspection plan and program. 

While track and structure inspections are performed by several methods, all inspection methods 

share a common approach to describing conditions as it relates to a degree of serviceability. 

These four levels of serviceability are 

•	 Fully Operational (Green/Minimal Wear), 

•	 Operational (Yellow/Damage and/or Wear), 

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• Restricted Operations (Red/Exceeds Tolerances), and 

• Safety Hazard (Black). 

Depending on the level of serviceability, there are prescribed actions required by the TRST 1000 

manual, ranging from speed restrictions to placing the section of track out of service. Speed 

restrictions are applied only when the components are defective from a safety point of view (i.e. 

when the safety of the track may be compromised). For components that are defective from a 

maintenance point of view, speed and/or other restrictions are imposed at the discretion of the 

track supervisor. 

The Track and Structure Maintenance Branch (TSMN) is responsible for maintaining all 

mainline track, special track work and yards. The Track and Structures Maintenance department 

is divided into two branches. (1) Track Maintenance (TKMN) and (2) Structures Maintenance 

(STRC). TKMN is further divided into two divisions (North and South). The TKMN Groups 

(North and South) are responsible for performing corrective maintenance on defects to tracks and 

other supporting infrastructure. Maintenance Managers review the work orders opened by Track 

Inspectors, assign labor codes to each work order, and set priorities for corrective maintenance 

work for the next 24 hours. 

The Track Production Capital Program Branch (TPCP) has responsibility for performing all 

capital budget track work system-wide. This includes, replacement of ties, turnouts, fasteners, 

running rail, floating slab and third rail insulators. TKMN work crews also support TPCP. 

3.2 Track Inspection 

Track inspectors are required to inspect every mile of the Metrorail mainline system twice per 

week, recording defects affecting any track asset within their field of view. These defects range 

from items requiring immediate attention (e.g. a broken frog or a bolt hole break at a joint) to 

slowly deteriorating conditions that need to be monitored (e.g. mild spalling on the rail head on a 

section of track). Track inspectors complete written reports, and log defects in WMATA’s 

enterprise asset management system (Maximo) with the objective of building a defect history 

that can be queried and visually displayed through the authority’s rail maintenance planning 

software (Optram), alongside data from the other inspection sources. 

The TRST 1000 manual specifies that applicants to the track inspector position must have at 

least one year of track-related experience. Accepted applicants complete 7 weeks of classes 

spread out over an 18-week training period, and upon passing several written quizzes and field 

assessments, are certified as track inspectors Class D. After every year of satisfactory 

performance, track inspectors are eligible to take a promotional test to qualify for the next level 

(C, B, A, and finally class AA, at 5 years of total trackwork experience). The promotional test is 

a term of the union contract and does not emphasize track inspection skills. However, WMATA 

track inspectors also are required to re-certify as track inspectors at their current level every two 

years, with a written test and field demonstration. 

Table 1 below shows the distribution of experience for the TKIN group. TKIN has seen a steady 

increase in the number of inspection personnel since 2010 (from 43 to 59), largely due to new 

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positions to support the Dulles Phase 1 (Silver Line) and the new Special Inspection Group 

(SIG), which supplements daily track inspection by targeting on specific issues or activities, such 

as switch and yard inspections. Dulles Phase II, projected to open by 2019, will add an additional 

twelve miles, requiring at least 4 more track inspectors. 

Table	1: Track	Walking	

Experience (March 2016)

Class Number

A (5+ years) 21

(4 years) 0

(3 years) 9

(2 years) 13

(1 year) 11

Trainee 5

Total 59

Inspection of the Metrorail system is divided into geographical regions: Dulles, which covers the 

N-Line, which opened in July 2014; Brentwood, which covers the A- and B-Lines; Branch 

Avenue, which covers the E-, L- and F-Lines; New Carrollton, which covers the D- and G-Lines, 

and the C-Line from Metro Center to Rosslyn; and Alexandria, which covers the C-Line from 

Arlington Cemetery through Huntington, the J-Line, and the K-Line. 

These geographic regions are further sub-divided into 25 track inspection territories. Each 2-

person track inspection team is assigned a single territory that ranges in length from just over 2 

miles to 6 miles. Each 2-person track inspection team is responsible for inspecting all running 

rails, third rails, track switches, and supporting components, including clips, fasteners, drainage 

system, and other related components within its territory. See Figure 2 on the next page. 

After the FWSO’s SMI, and extensive discussions with WMATA regarding resources for track 

inspection, in December 2015, WMATA revised the length of its track inspection territories, 

adding one new territory, ensuring no single territory was longer than 6 miles, and bringing the 

average territory length down to 4.3 miles from 5.7 miles. See Figure 3 below. 

The 2-person crews typically inspect Track 1 of their assigned territory on one day, and Track 2 

of their assigned territory on the next day. Special inspections are also conducted in their 

assigned territories for switches, special trackwork, and pocket tracks. In the middle of the week, 

track inspectors may also perform light maintenance, such as bolt torqueing or debris or 

vegetation removal. Track inspection during peak operating periods (7am- 10am, and 4pm-7pm) 

is no longer WMATA’s policy, due to increased train frequencies, which impact effectiveness 

and worker safety. Walking track inspection is largely accomplished in a 4-hour interval 

between the peak periods (10am – 2 pm). Track inspections are not currently conducted at night, 

with two exceptions: the Greenbelt test track and the B35 double-crossover, where clearance 

issues at these locations prevent track inspection under traffic. 

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Delineation of Track

Walker Inspection

Territories

Figure 2: WMATA Track Inspection Territories, 2016 

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2015 Track Inspection Territories 2016 Track Inspection Territories

Segment Miles MGT* Type Segment Miles MGT* Type

Rosslyn	-

D98 Core

D13-D09 (D98) 5.5 16 At-Grade D10 - D13 5.1 14 At-Grade

D09 (D98) -D05 3.93 37 Tunnel and Aerial D08 - D10, G-Line 3.9 37 Aerial and Tunnel

D05-D01 2.2 37 Tunnel D08 - D02 3.3 37 Tunnel

C05-C01 2.7 37 Tunnel C05 - D02 3.5 37 Tunnel

A and B

Line

A15-A11 7.2 21 At-Grade A15 - A12 5.8 21 At-Grade

A11-A07 5.8 27 Tunnel A12 - A09 4.7 27 Tunnel and At-Grade

A07-A01 5 27 Tunnel A09 - A04 5.1 27 Tunnel

B01-B35 1.3 27 Tunnel and Aerial A04 - B04 5.4 27 Tunnel

B35-B07 6 27 At-Grade and Aerial B04 - B08 5.5 27 At-Grade

B07-B11 6.5 18 Tunnel and At-Grade B08 - B11 5.2 16 Tunnel

and F

Line

E10-E06 7.2 16 Tunnel and Aerial E09 - E10 2.8 16 At-Grade

E06-E01 5.4 16 Tunnel E06 - E09 5.3 16 Tunnel and Aerial

F01 - F03 1 30 Tunnel E06 - F02 5.3 30 Tunnel

F03 -F06 2.6 15 Tunnel F02-F03 and L Line 4.5 30 Tunnel and Aerial

F06 - F11 6.8 15 At-Grade F03 - F08 4.9 15 Tunnel

F08 - F11 4.4 15 At-Grade

Line G05-G01 7 27 Tunnel and Aerial G01 - G05 5.5 27 Tunnel and Aerial

K Line K08-K05 7.5 17 At-Grade K08 - K06 5.4 17 At-Grade

K05-K01 5 30 Tunnel K06 - K02 5.6 30 At-Grade and Tunnel

N Line

N06-N93 (Wolf Trap) 3.7 17 At-Grade N06 - N02 5.8 17 At-Grade and Tunnel

N93 (Wolf Trap) -N02 3.8 17 At-Grade and Tunnel N02 - K98 5.7 17 At-Grade and Aerial

N02-K98 3.9 17 Aerial and At-Grade

J / C Line

J03-J01 7.4 13 At-Grade J02 - J03 3.9 13 At-Grade

C15-C07 6.9 31 At-Grade and Aerial J02-C13, C15-C13 4.6 31 At-Grade and Aerial

C07-C05 2.3 11 Tunnel C13 - C09 4.6 31 At-Grade and Aerial

C09-C05, C05-K02 5 30 Tunnel and At-Grade

L Line L-LINE 3.9 15 Aerial *Included in F02-F03 Segment

*Million Gross Tons (MGT) 

Figure 3: Comparison of Track Inspection Territories, 2015 and 2016 

Track inspection in underground sections is generally more difficult than outdoor track 

inspection. Visibility is poor; installed tunnel lighting is often dim or obscured by dust. Direct 

fixation track, characteristic of underground sections, is more complicated to inspect. The 

underground corridors in the Metrorail system typically have higher train frequencies and 

elevated catwalks, which makes clearing the track a more arduous process. 

Before 2006, each track inspector was certified through the RWP training program in place at 

that time, and worked under individual train detection, so both inspectors were inspecting track. 

After a series of accidents, which resulted in several worker fatalities between 2006 and 2009, 

this policy was changed to require one inspector to act as a watchman, whose sole duty is to 

watch for oncoming trains – not to inspect track. The other inspector of the two-person team is 

solely responsible for the visual inspection of a given territory. Roles are typically switched midweek. The impacts of this policy change on the quality of track inspection are the focus on 

FWSO’s SMI finding R-4-28-a, and FWSO and WMATA have been working cooperatively on 

this issue for the past several months. 

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Following an inspection, the track inspectors complete and file a daily inspection record of their 

activities and associated work activities. The form is included as Figure 4-1, section 4.1.1 of the 

TRST 1000 Manual. Further, track inspectors are required to maintain the Maximo database by 

“entering and modifying defect records as defects are found and progress in deterioration.” 

(TRST-1000 3.1.1.4) 

Per Operations Administrative Procedure (OAP) 208-01, track supervisors are required to review 

the daily inspection reports and conduct three field checks per week. FWSO’s interviews and 

observations confirmed that track supervisors historically have been unable to complete the three 

weekly field checks for track inspection teams under their charge. Also, this process is not 

formalized in a way that ensures active oversight and monitoring of track inspectors. For 

example, the track supervisor can complete field checks alone, negating the opportunity for 

training, mentoring and discussion with track inspectors regarding specific track conditions and 

the progress of deterioration for specific components in their territories. 

3.3 Track Maintenance 

TKMN is responsible for maintaining all mainline track, special track work and yards to a state 

of good repair. Work is typically assigned based on descending order of priority. If track 

inspectors find a defect during their walks, corrective action is required and varies, up to the 

suspension of train movement over a section of track, depending on the condition. If an 

inspection report notes a deficiency or defect, the technicians supporting TRST are required to 

enter a new Work Order, using WMATA’s Asset Management tool (Maximo) and assign it a 

Work Order Priority on a scale of 0 to 3. (Priority 0 is the most severe and requires track to be 

removed from service for corrective maintenance. Priority 1 requires speed restrictions until 

repair, Priority 2 requires monitoring and a possible speed restriction under certain 

circumstances, and Priority 3 indicates track in serviceable condition and requires no action.) 

TKMN then reviews the work order. Per TRST 2000, page 46, a maintenance manager is 

required to verify the condition and schedule work to address the deficiency or defect. Both OAP 

208-01 and TRST-1000 2.10.1 require track inspection reports to be saved for five years. This is 

accomplished through use of a shared network drive and database within TRST. 

WMATA’s amended Final Investigation Report on the August 6, 2015 D-Line Curve 306 

Derailment indicated that, while corrective maintenance is ongoing, preventive maintenance, 

including activities to tighten bolts and clear drains, is “on the back burner.” It also stated that 

senior mangers within TKMN believe that, in obtaining track rights, “priority is given to meeting 

high-level goals, such as replacing a certain number of ties or fasteners, which limits the ability 

to dedicate resources to Preventive Maintenance activities, such as verifying and correcting 

deficiencies identified by track inspectors.” 

During both the FWSO’s SMI and the FWSO’s track integrity investigation, the FWSO found 

that TRST as a department has difficulty completing all of the open work orders in the track time 

allotted to its maintenance crews. As of May 1, 2016, TRST had 13,954 track defects logged 

into Maximo in various stages of being open for track corrective maintenance, with 17,780 total 

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defects being tracked by TRST, including structures. The earliest open work orders date from 

2008, while the majority of open work orders date from 2015 and 2016. 

Specifically for track, Maximo showed: 

• 42 Priority 1 Defects (Black/Red) 

• 5,536 Priority 2 Defects (Yellow) 

• 8,371 Priority 3 Defects (Green) 

TRST addresses all 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. 

Priority 2 defects generally do not generally 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. Priority 3 Defects indicate minimal wear 

and do not require repair, but do require monitoring for further degradation. 

While WMATA attempts to address deficiencies or defects identified as Priority 1 or 2 as 

quickly as possible with available maintenance crews, these crews also perform other tasks, such 

as supporting the Capital Projects group, and are not always available to address these 

conditions. During the SMI, through March 2015, TRST reported 3,263 Priority 2 Defects. This 

shows a marked increase in documented Priority 2 Defects tracked in Maximo over the last year. 

TRST relies heavily on Maximo to track assets, preventive maintenance schedules and work 

orders, among other features. The Inspections and Maintenance groups both utilize Maximo to 

enter, update and close Work Orders, list tasks completed that are associated with the Work 

Order and track employees assigned to the Work Order. Through the SMI, the FWSO also 

issued several findings (R-7-40-a through R-7-40-c and R-7-41-a) that WMATA is working to 

address, regarding the quality of the data in Maximo. During the FWSO’s investigation, 

WMATA’s technical leadership confirmed that their level of confidence in the accuracy of the 

data currently in Maximo is approximately 75 percent. To address this situation, WMATA has 

hired a contractor to perform an entirely independent track inspection of the Metrorail system to 

re-populate the Maximo system with an accurate and consistently inputted baseline at the 

conclusion of the SafeTrack project. TRST also has established a Rail Analytics Group to 

carefully review and monitor Maximo data entry, and to run and validate reports. New training 

is also being developed for maintenance personnel on using Maximo and entering data. 

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4.0 Findings and Required Action 

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

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

• Category 1: Track Inspection Resources and Training 

• Category 2: TRST 1000 Manual 

• Category 3: Track Quality Oversight 

• Category 4: Track Construction and Maintenance 

Within these categories, FWSO 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, FWSO 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 FWSO approval of work plans, and the 

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

4.1 Track Inspection Resources and Training 

FWSO’s investigation found that the resources and training devoted to track inspection could be 

significantly improved to enhance effectiveness. FWSO’s team identified 4 findings regarding 

this topic. 

4.1.1 Situation

TRST does not provide its own initial training for track maintainers and track inspectors, but 

relies on WMATA's technical training division, which is currently undergoing re-organization. 

TRST personnel have expressed concerns regarding the quality of this training and the 

knowledge and expertise of some of the instructors on track-specific issues. TRST also uses 

contractors to provide specialty training and senior track inspectors support on-the-job training. 

In response to concerns previously discussed with the FWSO, WMATA is now working with the 

University of Tennessee to develop new track inspection training for inspectors and supervisors. 

• Finding 1: Track inspectors receive inadequate training. 

During inspections conducted as part of the track integrity investigation, FWSO inspectors 

noticed a lack of comprehension of TRST 1000 manual requirements among some track 

inspectors, as well as low ability to practically apply the standards. As an example, an FWSO 

inspection team encountered an issue with lack of knowledge regarding the application of third 

rail gauge threshold measurements. Specifically, at one location where the rail exhibited 

equipment striking the third rail, employees indicated that the third rail gauge was measured 

from the field side of the rail. The TRST 1000 indicates measurement from the gauge side of the 

near rail. 

More significantly, during the course of the investigation, and in subsequent follow-up 

inspections, FWSO inspectors found deficient track conditions requiring speed restrictions that 

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were missed by track inspectors, including instances of missing direct fixation or DF fasteners 

(up to 456 inches between effective DF fasteners) that should have been already noted and 

repaired. In other instances, questions regarding the cause or source of specific defects, from 

wheel burns, to spalling and corrosion, were incorrectly identified and the typical progression 

patterns and timelines for common defects were also not well understood. Many of the track 

inspectors encountered appeared to be inadequately trained with little or no hands-on-training. 

• Finding 2: There is insufficient time for track inspection. 

As of June 2016, WMATA has 54 certified track inspectors and 5 trainees (planned for Dulles 

Phase II), for a total of 59 track inspectors. Eight (8) supervisors oversee the 59 track inspectors 

from four locations (Branch Avenue, Alexandria, New Carrolton and Brentwood). Track 

inspection teams are assigned a permanent territory (they are not deployed to different areas 

week to week) based on an annual pick. They are responsible for inspecting each track twice per 

week, for a total of four track walks per week. Another day is used to inspect special trackwork, 

yard track, or tend to other maintenance concerns. 

In response to FWSO’s SMI finding R-4-28-a, regarding the impact that the change in inspection 

practices, with one inspector now serving as a watchman, has had on the overall level of 

resources devoted to inspections and their quality, WMATA is currently evaluating three-man 

teams, consisting of one watchman-lookout and two inspectors in the high tonnage, high train 

frequency D98 – Rosslyn corridor, to enhance safety and the quality of inspection. 

FWSO’s investigation confirmed that WMATA’s two-person inspection teams typically work 

from 7:30am to 4:00pm on weekdays with 4 hours of actual inspection time available between 

10:00am and 2:00pm. Track inspectors use safety walks and also walk on the right-of-way when 

conducting inspections. Track inspectors must clear for passing trains every 6 to 12 minutes, and 

typically spend between 20 and 40 minutes of their 4 hours of inspection time clearing for trains 

and waiting for trains to pass. 

In essence this means that one inspector spends 31⁄2 hours inspecting 4 to 5 miles of track each 

day while under the constant distraction of passing trains and the need to clear. The FWSO 

appreciates that WMATA has already modified its track territories and is considering the use of 

3-person inspection teams in the core in response to previous FWSO findings. However, the 

constraints placed on this inspection activity clearly limit its effectiveness. There is not the time 

to closely examine specific conditions or concerns or to use tools, such as rail wear gauges or 

Geismar gauges (retrieved from “Job Boxes” at different locations within the system). 

Also, per the Operations Administrative Procedure (OAP) 208-01, track supervisors are required 

to review the daily inspection reports and conduct three field checks per week. FWSO’s 

interviews and observations confirmed that track supervisors historically have been unable to 

complete the three weekly field checks for track inspection teams under their charge, due to a 

lack of time and resources. 

WMATA’s inspection plan must ensure sufficient time to inspect all tracks and special 

trackwork to the standard specified in the TRST 1000 Manual, and also provide ample time to 

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ensure performance of required supervisory inspections and inspections required to support the 

scheduling of maintenance work. WMATA’s track inspection plan must analyze the time 

required to conduct visual inspection of tracks in accordance with WMATA’s track safety 

standards, and ensure that high priority tracks are inspected as frequently as necessary to identify 

and monitor the progression of specific defects and combinations of conditions. WMATA’s 

inspection plan also must consider the characteristics of different tracks. 

•	 Finding 3: Excessive wear and deficient crosstie condition in special trackwork is 

not being identified and addressed. 

The FWSO’s team noted the difficulty of accessing certain locations, including turnouts, 

crossovers and other special trackwork during revenue service with limited inspection windows. 

While twice weekly walking inspections are supposed to include special trackwork in a given 

track inspector’s territory, interviews and observations indicated that track inspectors do not 

typically inspect these areas, and rely instead on the detailed monthly inspections. 

Throughout the track integrity investigation, the FWSO’s team found missing bolts and 

excessive wear in switches and crossovers, and deficient wood crossties in ballasted sections 

throughout the system. Further, the FWSO’s team found that detailed monthly inspections of 

switches and turnouts ranged in quality and thoroughness. 

More recently, in response to the July 29, 2016 derailment, the FWSO found poor crosstie 

condition, loose and missing fasteners, and evidence of excessive lateral rail movement. These 

conditions clearly exceeded allowable safety parameters specified in WMATA’s track safety 

standards, and were not identified or addressed by WMATA prior to the derailment. 

•	 Finding 4: The TGV is underutilized as part of WMATA’s track inspection 

program. 

Failure in a track segment generally follows a process from an undetected crack into defect, from 

defect to a failure, and from a failure to breakage. Automated technology can provide a useful 

tool in identifying defects earlier and accurately monitoring their progression. WMATA 

possesses its own TGV, and is working to bring all automated testing in-house. 

As of June 2016, WMATA has set an internal policy of using the TGV a minimum for four (4) 

times per year for track geometry and two (2) times per year for ultrasonic testing of the entire 

system. WMATA has already exceeded this annual testing policy on certain segments of the 

Red Line, and continues to receive new value from this vehicle as it integrates TGV runs into 

SafeTrack and on-going monitoring of other track locations. 

During the track integrity investigation, between late March and mid-April, FWSO team 

members accompanied WMATA’s TGV inspection team for ultrasonic inspection and track 

geometry inspection. During the ultrasonic testing ride, no significant defects (red or black) 

were found. Although the vehicle was stopped and reversed on several occasions to re-analyze 

data locations, only two (2) locations required on-the-ground, hand verifications for potential 

deficiencies cited; however, none were found. During the track geometry ride, WMATA 

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observed several conditions that required immediate corrective action. (A chase team was 

available in the case an out of service defect was captured and verified.) 

As of June 2016, WMATA had five (5) employees who are certified to analyze the ultrasonic 

technical data and hand-verify potential deficiencies identified by the TGV. Only one of these 

certified employees actively operates the TGV and serves on the TGV crew. (He is also 

responsible for the UT specialized components and maintenance for this area of the test vehicle.) 

WMATA is working to get other TGV crew members certified. 

As a result of the August 6, 2015 derailment, WMATA recently completed new guidelines for its 

TGV testing program. WMATA is also working to reduce the time required to generate results 

and ensure that information is provided to the Engineering Department immediately after testing. 

While WMATA is making greater use of the TGV, FWSO finds that WMATA’s overall track 

inspection program would benefit from expanding TGV use into full-time deployment. 

Establishing a full-time TGV crew and a full-time TGV testing schedule, and expanding 

resources for maintenance and calibration of the TGV, and the continual annual training and 

certification of the TGV crew, will supplement WMATA’s visual inspection program and 

enhance opportunities to identify and resolve defective track conditions before an incident. 

4.1.2 Findings and Required Actions

Metrorail Category 1: Track Inspection Resources and Training 

Findings Required Actions 

Finding 1 Track inspectors receive 

inadequate training. 

T-1 WMATA must develop additional track inspection training 

and certification requirements, and expand mentoring. 

Finding 2 There is insufficient time for 

track inspection. 

T-2 WMATA must establish a new track inspection plan that 

expands time available for track inspection through 

additional inspection shifts (i.e., evening and nighttime) and 

more frequent inspections of priority locations. 

Finding 3 Excessive wear and deficient 

crosstie condition in special 

trackwork is not being identified 

and addressed. 

T-3 WMATA must commit adequate resources and technically 

qualified personnel to the inspection of special trackwork and 

the completion of required corrective maintenance. 

Finding 4 The TGV is underutilized as part 

of WMATA’s track inspection 

program. 

T-4 WMATA must expand the use of the TGV in its track 

inspection program, and ensure the training and certification 

of the TGV crew. 

4.2 TRST 1000 Manual 

4.2.1 Situation

The TRST 1000 Track Maintenance and Inspection Manual, Revision 6, January 1, 2015 is 425 

pages in length, and includes in-depth information on track construction, maintenance and safety 

standards, requirements, and track engineering theory used at WMATA. Combining 

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construction, maintenance and safety standards together in one document makes the manual 

confusing for track inspectors, who need clear statements regarding inspection safety limits. 

Inspectors do have a field inspection manual, which is a selection of pages and tables excerpted 

from the full manual, but it also includes maintenance and construction information which is not 

relevant to inspection, and which confuses assessments that must be straight-forward and 

unambiguous from a safety perspective. Also, for track maintenance managers, the TRST 1000 

manual can be confusing in terms of establishing clear safety priorities for maintenance work, 

and assessing combinations of conditions with a greater potential risk than the ranking of their 

individual elements may indicate. 

•	 Finding 5: The TRST 1000 Manual is not a field document focused on inspection 

safety limits. 

WMATA needs a track inspection manual that specifies safety limits and the specific actions that 

should be taken by the inspector if track conditions are identified outside those safety limits. The 

TRST 1000 manual contains much “nice to know” information on track engineering principles 

and schematics. This information is not preemptively necessary for mission critical safety, and 

inadvertently creates a barrier in getting to the information most essential for track inspection. 

Safety limits are present in all of the rules reviewed; however, they are lost in the overabundance 

of data presented making the usage of this manual onerous in its present form. 

Further, for consistent application of any safety limit, there cannot be two contrasting criterion 

for field inspectors and supervisors to apply. The TRST 1000 Manual includes broad statements 

about both maintenance and safety standards that confuse understanding regarding minimum 

conditions that must be observed in the field prior to the issuance of a speed restriction. There 

should be one limit for all employees looking at safety items for top-to-bottom consistency. 

The TRST 1000 manual also contains outdated references and requirements, which must be 

corrected. In addition, critical information regarding the filing and management of inspection 

reports is outdated, and needs to be corrected. 

Finally, the TRST 1000 Manual does not reflect how the Track Geometry Vehicle or TGV is 

actually used at WMATA to support track inspection. For example, the TRST 1000 manual 

currently requires track inspectors to conduct “a detailed walking inspection of super elevation 

and gauge on all curves and spirals at least every 4 months.” However, WMATA track 

inspectors do not perform this activity, instead the TGV is used for assessing super elevation and 

gauge on curves and spirals. Also, as WMATA transitions away from contractors to operating 

and managing its own TGV program, the agency needs additional procedures to clarify how it 

will manage scheduling of TGV run-throughs that may be missed while the TGV is being 

maintained or calibrated, or while it may be out-of-service pending repair or upgrade. 

•	 Finding 6: WMATA does not have a clear process in place for track inspectors and 

supervisors to impose and remove speed restrictions. 

The procedure for WMATA track inspectors and supervisors to use the TRST 1000 manual to 

assess track conditions and clearly identify which conditions warrant speed restrictions is not 

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well understood by track inspectors or track supervisors, and requires additional support from 

track engineering. 

The TRST 1000 manual currently states, “Speed restrictions are to be applied only when the 

components are defective from a safety point of view (i.e. when the safety of the track may be 

compromised). For components, which are defective from a maintenance point of view, speed 

and/or other restrictions are imposed at the discretion of the track supervisor.” This statement 

has enormous impact on WMATA’s track inspectors. Some track inspectors encountered by the 

FWSO teams in the field were reluctant to place speed restrictions due to fear of punitive redress 

or the difficulty of arguing a situation based on the TRST 1000 manual. 

During the track integrity investigation, the FWSO team members conducted independent 

inspections with WMATA’s track inspectors and supervisors and found inconsistent practices 

regarding conditions that would necessitate a speed restriction. Further, the lack of an appeal or 

“good faith challenge” process means that track inspectors with safety concerns have no redress 

if the supervisor does not agree. In some instances, due to the size of the WMATA system, 

supervisors are not available to immediately review track conditions in the field, and may make 

assessments based on photographs or videos. Track Engineering is currently only called in to 

review a situation in rare instances, but provides a potentially valuable resource to mediate 

challenges and address concerns regarding track conditions. 

4.2.2 Findings and Required Actions

Metrorail Category 2: TRST 1000 Manual 

Findings Required Actions 

Finding 5 The TRST 1000 Manual is not a 

field document focused on 

inspection safety limits. 

T-5 WMATA must revise the TRST 1000 manual, or establish a 

separate track inspection manual, focused on inspection 

safety limits. 

Finding 6 WMATA does not have a clear 

process in place for track 

inspectors and supervisors to 

impose and remove speed 

restrictions. 

T-6 WMATA must establish a clear process for imposing and 

removing speed restrictions. 

4.3 Track Quality Oversight 

FWSO’s investigation found that track maintenance quality and oversight could be significantly 

improved. FWSO’s team identified 4 findings regarding this topic. 

4.3.1 Situation

As discussed in Section 3 of this report, the results of track inspections are documented on daily 

inspection reports, which record track inspector activities and observations. These reports are 

entered into WMATA's Maximo work order system. Paper inspection records are retained for 

cross-reference. 

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If track inspectors find deficiencies or defects, a new Work Order must be opened in Maximo 

and assigned a Work Order Priority. The Work Order is then supposed to be reviewed by the 

Track Maintenance branch. Per TRST 2000, a maintenance manager is required to verify the 

condition and schedule work to address the deficiency or defect. 

•	 Finding 7: WMATA fails to use inspection data to inform and prioritize track 

maintenance. 

TKMN maintenance managers, almost entirely on their own, are required to capture deficiencies 

and defects from the TKIN branch and relay the appropriate priority level to their TKMN 

assistant superintendents for work scheduling. In interviews conducted with FWSO’s teams, it 

was reported that field verification is not routinely completed regarding the defects identified by 

track inspectors, due to time and resource limitations. 

And, while track inspectors, over time, are required to maintain the Maximo database by 

“entering and modifying defect records as defects are found and progress in deterioration.” 

(TRST-1000 3.1.1.4), FWSO’s investigation found that most reports in Maximo do not appear to 

have been updated or changed after their date of creation. Therefore, maintenance managers may 

not have the most current information in evaluating and scheduled necessary work. 

WMATA's report on the August 6, 2015 derailment highlights the organizational separation of 

the Track Inspection and Maintenance branches within TRST. As evidenced in the revised 

investigation report, track inspectors routinely reported a lack of knowledge regarding how the 

other operational group functions and how their inspection reports are used. Track Inspectors 

reported rarely receiving any feedback or questions about any of their reports. Some maintenance 

managers reported contacting inspectors for more information about a reported condition, but 

that this was not a formal policy or practice. 

The FWSO finds that additional coordination between TKIN and TKMN would enhance the 

likelihood that maintenance work scheduled addresses the highest priority issues and concerns. 

•	 Finding 8: Maintenance managers require additional training and resources to act 

on inspection data. 

Currently, maintenance managers are among the newest managers in the TKMN branch and have 

varying levels of training and experience in track repair/maintenance and general management. 

Maintenance managers receive little formal training curriculum upon their hiring or promotion, 

and WMATA has little written guidance regarding how this process should be managed, and 

how time constraints and the lack of field verification should be factored into the scheduling of 

work. Track inspection reports in Maximo may not be updated, or may not fully reflect 

progression of deterioration in track system components. 

•	 Finding 9: Current inspection and maintenance activity does not adequately address 

tunnel drainage system. 

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The FWSO’s teams believe that the single most valuable action WMATA could take to preserve 

its track integrity is to place a clear priority on maintaining and unclogging drains in tunnels. 

During May, when the drains were unclogged and restored to good condition on a stretch of the 

Red Line between Medical Center and Friendship Heights, WMATA employees informed 

FWSO that this type of work on the drainage system, including mud removal and clearing of 

drains, had not been performed in many years. FWSO’s team found that after this work began, 

there was a substantial improvement in water remediation and dryness in the tunnel. Given the 

corrosive and deleterious effects of water on track infrastructure, the FWSO finds that drain 

maintenance should be a much higher priority in WMATA’s overall track inspection and 

maintenance program. 

•	 Finding 10: Additional supervision is needed for both track inspection and track 

maintenance activities. 

A consistent finding through the FWSO’s investigation is that, given the size of the WMATA 

system and challenges of accessing the right-of-way, WMATA’s TKIN and TKMN management 

and supervision teams are significantly understaffed. Field checks and verification activities, for 

both inspection and maintenance activities, required in OAP 208-01, are not completed due to a 

lack of time and resources. Records reviews and observations of track inspectors performing 

their work indicate that “areas of concern” with the track structure, shared with FWSO’s teams, 

are identified, but work is not scheduled to address them. Oversight is limited for track 

inspectors and track maintainers, and FWSO’s team identified quality issues with both groups 

that could be readily addressed with additional field supervision, mentoring and discussion with 

track inspectors regarding specific track conditions and the progress of deterioration for specific 

components in their territories. 

4.3.2 Findings and Required Actions

Metrorail Category 3: Track Quality Oversight 

Findings Required Actions 

Finding 7 WMATA fails to use 

inspection data to inform and 

prioritize track maintenance. 

T-7 WMATA must develop a formal procedure and protocol to 

ensure the maintenance managers and track inspectors share 

information and jointly establish maintenance priorities. 

Finding 8 Maintenance managers require 

additional training and 

resources to act on inspection 

data. 

T-8 WMATA must provide additional training and resources to 

maintenance managers related to the use of inspection 

information to establish maintenance priorities. 

Finding 9 Current inspection and 

maintenance activity does not 

adequately address tunnel 

drainage system. 

T-9 WMATA must ensure that track inspectors and maintenance 

managers prioritize drainage defects. 

Finding 10 Additional supervision is 

needed for both track 

inspection and track 

maintenance. 

T-10 WMATA must provide additional supervisory staff or 

contractors to oversee track inspection and track maintenance 

activities and ensure conformance with WMATA track safety 

standards. 

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Final Report – Track Integrity Investigation 

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4.4 Track Construction and Maintenance 

FWSO’s investigation found track construction and maintenance issues to be resolved. FWSO’s 

team identified 3 findings regarding this topic. 

4.4.1 Situation

The TRST 1000 manual states that direct fixation or DF fastener stud anchor bolts from a 

“maintenance standpoint” shall not exceed more than 3 inches above the rail base. FWSO’s 

investigation team found numerous instances where bolt lengths exceeded 3 inches, where bolts 

had been cut off, and where bolts were improperly installed. FWSO’s investigation team also 

identified many instances of missing fasteners in direct fixation track. 

•	 Finding 11: WMATA does not apply the same quality control testing program to its 

force account installed fasteners that it would apply to those installed by a 

contractor while building a new line segment. 

FWSO’s investigation team confirmed inappropriate installation on stud anchor bolts and 

fasteners in direct fixation track. FWSO’s investigation team recognizes the difficulty and time 

required to manage transverse and longitudinal invert rebar when installing anchor bolts. When 

transverse rebar is encountered during the drilling operation, a new hole location is to be selected 

and new layout measurements taken from that point to avoid the rebar installation pattern. 

Longitudinal rebar if in the path way of the rail cannot be avoided and must be drilled through to 

achieve the minimum embedment. (At WMATA, finder studs were installed during the original 

invert construction to identify start points of rebar patterns in order to avoid the transverse rebars. 

Pacometers also can be used to find and help avoid embedded rebar.) 

FWSO’s investigation team observed construction contractors cutting anchor bolts off rather 

then relocating drilled holes or drilling through the rebar. FWSO noted numerous instances of 

cut bolts in track beds. FWSO’s inspectors also observed incorrect installation procedures to 

avoid longitudinal rebar. Finally, the FWSO investigation team also confirmed that TRST does 

not conduct the 6,000 lb. unrestrained pull tests required during new construction. This test, 

required for new construction, determines whether the anchor bolts have achieved the design 

hold down strength for the track fasteners. 

FWSO’s investigation team also found that the vast majority of bolted rail joints in direct 

fixation track or crossties with resilient fastening systems are missing rail clips. While not an 

immediate safety concern such a condition creates a weak point when other types of more critical 

defects occur at the same spot. 

•	 Finding 12: In certain instances, WMATA uses welding practices inconsistent with 

its construction standards to install cables to ensure train control and electrical 

continuity around mechanical joints. 

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Final Report – Track Integrity Investigation 

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FWSO’s inspection team found many CADWELD C bonds on the heads of rail that were 

broken. A C bond is small gauge rail head bond, used in pairs as power bonds at rail joints, 

welded on both ends to the field side of the heads of the rails. C bonds support cross-bonding 

between tracks, providing a connector for the negative return system, and also support the train 

control system. Because of their location, these C bonds can be broken, frayed or severed in the 

course of normal train operations. In addition, CADWELD C bonds on rail heads can affect the 

metallurgical and grain structure of the rail head, making it more prone to cracks. As a result, 

WMATA revised its design and construction specifications several years ago to replace 

CADWELD C bonds with huck bolted bonds in the webs of the rail to provide a stronger nonwelded bond. Huck bolts are compression fasteners that do not frequently break off, and do not 

compromise return current flow or the integrity of the rail. 

Huck bolted bonds do require special components for installation, and under certain conditions, 

WMATA’s ATC Branch, when making emergency repairs or addressing priority repairs, uses 

the CADWELD C bonds by default. These bonds are then marked for replacement with huck 

bolted bonds. However, FWSO team members found numerous instances where CADWELD C 

bonds that had not been replaced with huck bolts as required, and were broken, frayed or 

otherwise damaged. 

4.4.2 Findings and Required Actions

Metrorail Category 4: Track Construction and Maintenance 

Findings Required Actions 

Finding 11 WMATA does not apply the 

same quality control testing 

program to its force account 

installed fasteners that it would 

apply to those installed by a 

contractor while building a new 

line segment. 

T-11 WMATA must develop a special inspection and repair plan 

to address inappropriate stud bolt installation and missing 

fasteners, and ensure track maintainers and contractors are 

trained in stud bolt installation and rail clip installation, and 

that work is adequately overseen. 

Finding 12 In certain instances, WMATA 

uses welding practices 

inconsistent with its construction 

standards to install cables to 

ensure train control and 

electrical continuity around 

mechanical joints. 

T-12 CADWELD C-bonds must be identified and replaced with 

huck bolted cables in the webs of the rail as specified in 

WMATA’s standards. 

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Final Report – Track Integrity Investigation 

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Attachment A: Findings and Required Actions Matrix 

Metrorail Category 1: Track Inspection Resources and Training 

Findings Required Actions 

Finding 1 Track inspectors receive 

inadequate training. 

T-1 WMATA must develop additional track inspection training 

and certification requirements, and expand mentoring. 

Finding 2 There is insufficient time for track 

inspection. 

T-2 WMATA must establish a new track inspection plan that 

expands time available for track inspection through additional 

inspection shifts (i.e., evening and nighttime) and more 

frequent inspections of priority locations. 

Finding 3 Excessive wear and deficient 

crosstie condition in special 

trackwork is not being identified 

and addressed. 

T-3 WMATA must commit adequate resources and technically 

qualified personnel to the inspection of special trackwork and 

the completion of required corrective maintenance. 

Finding 4 The TGV is underutilized as part 

of WMATA’s track inspection 

program. 

T-4 WMATA must expand the use of the TGV in its track 

inspection program, and ensure the training and certification 

of the TGV crew. 

Metrorail Category 2: TRST 1000 Manual 

Findings Required Actions 

Finding 5 The TRST 1000 Manual is not a 

field document focused on 

inspection safety limits. 

T-5 WMATA must revise the TRST 1000 manual, or establish a 

separate track inspection manual, focused on inspection 

safety limits. 

Finding 6 WMATA does not have a clear 

process in place for track 

inspectors and supervisors to 

impose and remove speed 

restrictions. 

T-6 WMATA must establish a clear process for imposing and 

removing speed restrictions. 

Metrorail Category 3: Track Quality Oversight 

Findings Required Actions 

Finding 7 WMATA fails to use inspection 

data to inform and prioritize track 

maintenance. 

T-7 WMATA must develop a formal procedure and protocol to 

ensure the maintenance managers and track inspectors share 

information and jointly establish maintenance priorities. 

Finding 8 Maintenance managers require 

additional training and resources 

to act on inspection data. 

T-8 WMATA must provide additional training and resources to 

maintenance managers related to the use of inspection 

information to establish maintenance priorities. 

Finding 9 Current inspection and 

maintenance activity does not 

adequately address tunnel drainage 

system. 

T-9 WMATA must ensure that track inspectors and maintenance 

managers prioritize drainage defects. 

Finding 10 Additional supervision is needed 

for both track inspection and track 

T-10 WMATA must provide additional supervisory staff or 

contractors to oversee track inspection and track maintenance 

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Final Report – Track Integrity Investigation 

Washington Metropolitan Area Transit Authority 

maintenance. activities and ensure conformance with WMATA track safety 

standards. 

Metrorail Category 4: Track Construction and Maintenance 

Finding 11 WMATA does not apply the same 

quality control testing program to 

its force account installed fasteners 

that it would apply to those 

installed by a contractor while 

building a new line segment. 

T-11 WMATA must develop a special inspection and repair plan 

to address inappropriate stud bolt installation and missing 

fasteners, and ensure track maintainers and contractors are 

trained in stud bolt installation and rail clip installation, and 

that work is adequately overseen. 

Finding 12 In certain instances, WMATA 

uses welding practices inconsistent 

with its construction standards to 

install cables to ensure train 

control and electrical continuity 

around mechanical joints. 

T-12 CADWELD C-bonds must be identified and replaced with 

huck bolted cables in the webs of the rail as specified in 

WMATA’s design and construction standards. 

Federal Transit Administration August 8, 2016 36