PB96-916304

NTSB/RAR-96/04

NATIONAL

TRANSPORTATION

SAFETY

BOARD

WASHINGTON, D.C. 20594

RAILROAD ACCIDENT REPORT

COLLISION OF WASHINGTON METROPOLITAN

AREA TRANSIT AUTHORITY TRAIN T-111 WITH

STANDING TRAIN AT SHADY GROVE PASSENGER

STATION, GAITHERSBURG, MARYLAND

JANUARY 6, 1996

6676A
Abstract: On January 6, 1996, Washington Metropolitan Area Transit Authority (WMATA)

Metrorail subway train No. T-111 failed to come to a stop at the above-ground Shady Grove,

Maryland, passenger station, the final station on the Metrorail Red Line. The four-car train ran by

the station platform and continued about 470 feet into the Metrorail yard north of the station,

where it struck a standing, unoccupied subway train that was awaiting assignment. The operator

of train T-111 was fatally injured; the train’s two passengers were not injured. Total property

damages were estimated to be between $2.1 and $2.6 million.

The safety issues discussed in this report are adequacy and appropriateness of WMATA

methods of management, decisionmaking, and communication; safety implications of the

decision to eliminate routine manual train operation on the Metrorail system; effectiveness of

using performance levels to control train speed; compatibility between railcar braking

performance and design of the automatic train control system; and adequacy of WMATA and

Montgomery County emergency response procedures.

As a result of its investigation, the National Transportation Safety Board issued

recommendations to the Washington Metropolitan Area Transit Authority, the Federal Transit

Administration, the American Public Transit Association, the Montgomery County Fire and Rescue

Commission, and all jurisdictions providing primary and secondary response to Metrorail accidents

or incidents.

The National Transportation Safety Board is an independent Federal agency dedicated to

promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety.

Established in 1967, the agency is mandated by Congress through the Independent Safety Board

Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents,

issue safety recommendations, study transportation safety issues, and evaluate the safety

effectiveness of government agencies involved in transportation. The Safety Board makes public its

actions and decisions through accident reports, safety studies, special investigation reports, safety

recommendations, and statistical reviews.

Information about available publications may be obtained by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

(202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(703) 487-4600
COLLISION OF WASHINGTON METROPOLITAN AREA

TRANSIT AUTHORITY TRAIN T-1 11 WITH

STANDING TRAIN AT SHADY GROVE PASSENGER

STATION, GAITHERSBURG, MARYLAND

JANUARY 6, 1996

RAILROAD ACCIDENT REPORT

Adopted: October 29,1996

Notation 6676A

NATIONAL

TRANSPORTATION

SAFETY BOARD

Washington, D.C. 20594

iii

CONTENTS

EXECUTIVE SUMMARY.........................................................................................................................v

INVESTIGATION

Synopsis ........................................................................................................................................................1

Pre-accident Events.......................................................................................................................................1

The Accident.................................................................................................................................................3

Injuries...........................................................................................................................................................7

Train Damage................................................................................................................................................7

Personnel Information.................................................................................................................................10

Train Operator.....................................................................................................................................10

OCC Radio Controller.........................................................................................................................11

OCC Button Controller .......................................................................................................................12

Train Information........................................................................................................................................12

Train T-111 .........................................................................................................................................12

Gap Train.............................................................................................................................................14

Site Description...........................................................................................................................................14

Operations Information ...............................................................................................................................14

Operations Control Center (OCC).......................................................................................................14

OCC Staffing.......................................................................................................................................16

Signal and Train Control Information.........................................................................................................16

Automatic Train Control.............................................................................................................................16

Train-Wayside Communication (TWC)..............................................................................................17

Performance Levels.............................................................................................................................17

Railcar Braking System...............................................................................................................................18

Wheel Flats and Tests of the Slip/Slide System .........................................................................................20

Meteorological Information ........................................................................................................................23

Medical and Pathological Information........................................................................................................23

Wreckage.....................................................................................................................................................24

Emergency Response ..................................................................................................................................24

Communications Between OCC and Rescue Personnel .....................................................................29

Training ...............................................................................................................................................29

Third Rail Schematic Availability.......................................................................................................29

Warning Strobe and Alarm Devices....................................................................................................30

Accident Site Configuration/Control of Third Rail Power.................................................................30

Tests and Research......................................................................................................................................30

Sight Distance Tests............................................................................................................................30

Signal System and Speed Command Tests .........................................................................................30

Brake Equipment Tests .......................................................................................................................32

Train Stopping Distance Tests............................................................................................................32

Gap Train Light Bulb Tests.................................................................................................................33

Train T-111 Inspection Test for Wheel Flats......................................................................................34

Other Information........................................................................................................................................34

Oversight of Metrorail.........................................................................................................................34

Management and Organizational Factors............................................................................................35

Manual Versus Automatic Operation on the Metrorail System..........................................................35

Maximum Authorized Speed (MAS) ..................................................................................................37
iv

Station/Platform Overruns on the Metrorail System...........................................................................40

Training of OCC Controllers...............................................................................................................42

Gap Train Placement...........................................................................................................................42

Metrorail Operating Rules...................................................................................................................43

Event Recorders ..................................................................................................................................44

Postaccident Policy/Rule Changes......................................................................................................45

Gap Train Placement ...................................................................................................................45

Maximum Speed in Inclement Weather......................................................................................45

OCC Controller Training.............................................................................................................45

Previous Metrorail Fatal Accident ......................................................................................................46

ANALYSIS

General ........................................................................................................................................................48

The Accident...............................................................................................................................................48

Elimination of Routine Manual Train Operation........................................................................................49

Use of Performance Levels to Control Train Speed ...................................................................................51

Maximum Authorized Speed ......................................................................................................................52

Railcar Braking Performance and Design of the ATC System...................................................................52

Adherence to Operating Rule Change Procedures......................................................................................54

Gap Train Placement...................................................................................................................................55

Metrorail Reliance on Oral Instructions .....................................................................................................55

WMATA Management, Decisionmaking, and Communication.................................................................56

OCC Controller Training ............................................................................................................................58

Performance of Controllers and Train Operator.........................................................................................58

The OCC Environment........................................................................................................................58

Train Operator’s Actions During the Accident Sequence...................................................................60

Train Operator’s Use of Prescription Medications.............................................................................61

Event Recorders..........................................................................................................................................62

Emergency Response ..................................................................................................................................62

Crashworthiness of Metrorail Cars.............................................................................................................65

Station/Platform Overruns on the Metrorail System...................................................................................65

CONCLUSIONS........................................................................................................................................67

PROBABLE CAUSE ................................................................................................................................69

RECOMMENDATIONS..........................................................................................................................70

APPENDIXES

Appendix A--Investigation..................................................................................................................73

Appendix B--November 17, 1995, Notice to All OCC Personnel ......................................................75

Appendix C--Train T-111 Speed Calculation Chart ...........................................................................77

Appendix D--February 14, 1996, Memorandum, Subject: ATC Block Design..................................79

Appendix E--Signal System and Speed Command Test Results ........................................................81

Appendix F--Train Stopping Test Results ..........................................................................................85

Appendix G--November 20, 1995, Memorandum, Subject: Manual Train Operation .......................87

Appendix H--Previous Safety Recommendations Issued to WMATA...............................................89

Appendix I--Amtrak Medication Information Brochure .....................................................................97
v

EXECUTIVE SUMMARY

bout 10:40 p.m. on January 6, 1996,

Washington Metropolitan Area Transit

Authority (WMATA) Metrorail subway

train No. T-111, operating on the “Red Line”

segment of the Metrorail system, failed to stop

as it entered the above-ground Shady Grove

passenger station near Gaithersburg, Maryland,

the final station on the Red Line. The four-car

train ran by the station platform and continued

about 470 feet into the Metrorail yard north of

the station, where it struck a standing,

unoccupied subway train that was awaiting

assignment. The T-111 train operator was fatally

injured; the train’s two passengers were not

injured. Total property damages were estimated

to be between $2.1 and $2.6 million.

The Safety Board determines that the

probable cause of this accident was the failure

of Washington Metropolitan Area Transit

Authority management and board of directors

(1) to fully understand and address the design

features and incompatibilities of the automatic

train control system before establishing

automatic train operation as the standard

operating mode at all times and in all weather

conditions, (2) to permit operating department

employees, particularly Operations Control

Center controllers and supervisors, to use their

own experience, knowledge, and judgment to

make decisions involving the safety of Metrorail

operations, and (3) to effectively promulgate

and enforce a prohibition against placing

standby trains at terminal stations on the same

track as incoming trains. Contributing to the

severity of the injuries to the train operator was

the disproportionate amount of crush sustained

by the lead cars of the colliding trains.

In its investigation of this accident, the

Safety Board addressed the following safety

issues:

• Adequacy and appropriateness of

WMATA methods of management,

decisionmaking, and communication;

• Safety implications of the decision to

eliminate routine manual train

operation on the Metrorail system;

• Effectiveness of using performance

levels to control train speed;

• Compatibility between railcar

braking performance and design of

the automatic train control system;

and

• Adequacy of WMATA and

Montgomery County emergency

response procedures.

As a result of its investigation of this

accident, the Safety Board issued safety

recommendations to the Washington Metropolitan Area Transit Authority, the Federal Transit

Administration, the American Public Transit

Association, the Montgomery County

(Maryland) Fire and Rescue Commission, and

all jurisdictions providing primary and

secondary response to Metrorail accidents or

incidents.

A

INVESTIGATION

Synopsis

bout 10:40 p.m. on January 6, 1996,

Washington Metropolitan Area Transit

Authority (WMATA) Metrorail subway

train No. T-111, operating on the “Red Line”

segment of the Metrorail system, failed to stop

as it entered the above-ground Shady Grove

passenger station near Gaithersburg, Maryland,

the final station on the Red Line. The four-car

train ran by the station platform and continued

about 470 feet into the Metrorail yard north of

the station, where it struck a standing,

unoccupied subway train (a 6-car “gap” train1

)

that was awaiting assignment. The train operator

was fatally injured; the two passengers on the

train were uninjured.

Pre-accident Events

At 6:40 a.m. on Saturday, January 6, 1996,

the National Weather Service issued a winter

storm warning, extending through Saturday

night and into Sunday, for northern Virginia and

central and southern Maryland, including the

Washington, D.C., metropolitan area. Snow was

expected to begin Saturday evening, to become

heavy at times after midnight, and to continue

through Sunday. Total snow accumulations were

expected to exceed 12 inches in many locations,

including the Washington metropolitan area.

According to Safety Board interviews,

WMATA2

 prepared for the predicted adverse

weather by opening its snow command center at

WMATA headquarters at 5:00 p.m. on January

6 and by holding a “snow meeting” of managers

 1

A gap train is a backup train that is positioned where

it can be placed in passenger service quickly if an inservice train malfunctions and must be replaced or if the

system experiences an unexpected service demand.

2

WMATA (pronounced WAH-MAHT-AH) has

responsibility for both the Metrorail and Metrobus systems

that serve Washington, D.C., and its suburbs. Although

some WMATA management officials have responsibility

for both rail and bus services, the focus of this report is

exclusively on the Metrorail system.

and supervisors at 7:00 p.m. (See figure 1 for an

overview of selected WMATA and Metrorail

organizational elements.) After the emergency

meeting, the WMATA deputy general manager

for operations left the headquarters, saying that

he would return later that evening. The assistant

general manager for rail services and the general

superintendent for rail transportation remained

in the command center, which was located on a

floor above the Metrorail Operations Control

Center (OCC), from which teams of controllers

monitor and direct operations throughout the

Metrorail system.

A utility assistant superintendent3

 was

scheduled to be the senior supervisor on duty in

the OCC on January 6; however, because of the

expected storm, the OCC superintendent elected

to report for duty about 9:30 p.m. and to assume

charge of the “midnight” shift, which began at

10:00 p.m. The OCC superintendent said that

when he relieved the on-duty assistant

superintendent, he asked for a status report and

was told that the system was operating normally.

The employees who would work that

evening as the OCC radio and button controllers

on the Red Line reported for work about 9:45

p.m.

4

 The button controller stated that it was a

 3

A utility assistant superintendent is an employee who

is qualified to work as an assistant superintendent of the

OCC, although this is not his regularly assigned position.

4

As was normal practice, two OCC controllers were

assigned to the Red Line at the time of the accident. One

controller was the radio controller. The radio controller

communicates with train operators and is responsible for

ensuring conformance with policies and procedures. The

radio controller also communicates with supervisory

persons and car equipment personnel in the field. The other

controller was the button controller. The button controller

is responsible for such tasks as setting route alignments and

signals, setting train performance levels, and coordinating

the replacement of trains when necessary. The radio

controller has more responsibility and authority than the

button controller in dealing with train operators.

A

3

normal shift change, and that the system was not

experiencing any problems.

All Metrorail trains were functioning in

mode 1, or automatic train operation, which

meant that train acceleration, speed, and braking

were under the control of the automatic train

control (ATC) system, with the train operator

responsible primarily for monitoring train

functions and ensuring safe operations. Under

the automated system, button controllers in the

OCC set the operating parameters for trains by

assigning “performance levels” to trains

operating over various route segments across the

Metrorail system. These performance levels set

a train’s acceleration rate and its top speed,

within the boundaries of the maximum “design”

or “limiting” speed for a particular route

segment. (See “Automatic Train Control”

section below for a detailed discussion of the

ATC system, train operating modes, and

performance levels.)

Under a WMATA policy promulgated in a

November 17, 1995, “notice” from the OCC

superintendent to OCC controllers (appendix B),

controllers were not permitted to authorize train

operators to change from mode 1 (automatic) to

mode 2 (manual) train operation except in

emergencies. Adjustments to train performance,

such as those that may be necessitated by

adverse weather conditions, were to be

accommodated solely by changing performance

levels in the affected areas.

Washington National Airport reported snow

beginning at 9:10 p.m. The two Red Line

controllers stated that radio transmissions and

train operations were normal until some time

after 10:00 p.m., when the OCC began to

receive reports of trains overrunning station

platforms because of slippery tracks. The button

controller stated that he and the radio controller

were concerned about the overruns and that, on

several occasions between 10:00 and 10:30

p.m., he (the button controller) asked the OCC

superintendent for permission to allow train

operators to change to manual mode. He said

that each time he asked, permission was denied.

In Safety Board interviews, the OCC

superintendent stated that, while he did not

recall any specific discussions or questions

about changing operating modes, if he had been

asked, he would have denied permission

because he had been instructed not to authorize

manual operation except in an emergency.

The Accident

At 10:18:07 p.m.,5

 the operator of train T110 (the train immediately preceding accident

train T-111) reported to the Red Line OCC radio

controller that slippery tracks had caused his

train to overrun the Twinbrook station platform

by one car. (See figure 2.) The controller

instructed the operator of train T-110 to

continue to operate in automatic mode. At

10:22:50 p.m., the button controller entered a

performance level of 8 (the most restrictive

level) for trains servicing the Twinbrook Station

on the outbound (toward Rockville) No. 2 track.

For this route segment (between the Twinbrook

and Rockville stations), performance level 8

limited a train’s top speed to 49 mph, with onehalf the normal rate of acceleration.

According to the system log (syslog),6

 radio

transcripts, and the Metrorail maintenance and

reliability system (MARS) report, the operator

of accident train T-111 (immediately behind

train T-110) had no problems servicing the first

21 of the 23 station stops between the Wheaton

and Shady Grove stations. But at 10:27:35 p.m.,

while operating on No. 2 track, he radioed the

OCC to report that his train had overrun the

Twinbrook station by all four cars. According to

the syslog, train T-111 had departed the

previous station, White Flint, with a

performance level of 3, which limited its top

speed between White Flint and Twinbrook to 44

 5

Times are reference times taken from the WMATA

recording unit that records both radio transmissions and

internal OCC communications picked up by overhead

microphones. All references to radio communications are

based on audio tapes and/or transcriptions.

6

The system log is a computer-generated summary and

record of certain operations of the Metrorail system. The

data include details of the functioning of the automatic

train operation, automatic train control, and automatic train

supervision systems, as well as route and signal

information and the times that trains enter track circuits.
4

Figure 2 – WMATA Metrorail Red Line and route of train T-111
5

mph. When the train operator reported his

overrun of the Twinbrook station, he was

instructed by the OCC Red Line radio controller

not to service the station (by discharging and

picking up passengers) but to proceed to the

next station, Rockville, while continuing to

operate in automatic mode. The train operator

proceeded under the performance level 8 that his

train had been assigned as it passed through

(overran) the Twinbrook station.

At 10:31:55 p.m., the operator of train T111 called the Red Line controller to report that

he had overrun the Rockville station platform by

one car. Because the train was partially off the

platform, its doors would not open

automatically, although the train operator could

override this protective system if necessary. The

controller instructed the train operator to “drop

[open] the left and right breakers” (to keep the

doors from opening on the first car) and to

service the station off the second, third, and

fourth cars.

When train T-111 entered the Rockville

station, the main train control system

electronically transmitted to it the performance

level 3 that was in effect for that station and that

would have limited train T-111’s top speed over

the 2.68-mile route segment between the

Rockville and Shady Grove stations to 59 mph,

with a normal rate of acceleration. This

performance level transmission was suspended

while the train serviced the station. When the

train finished servicing the station, the

performance level was reestablished. But

because the lead car of the train was outside the

station limits, performance level 3 was lost and

the train’s speed control system defaulted to

performance level 1 as the train departed the

station.

At 10:35:30, shortly after leaving the

Rockville station, the operator of train T-111

radioed the OCC to report console speed

readouts of 75 limiting and 75 regulated.7

 7

Operators’ consoles on all Metrorail trains display

three speed readouts. (See figure 3.) The first readout is the

automatic train protection, or ATP speed (labeled and

sometimes referred to as the “limiting” speed and

representing the maximum speed the ATP system, because

Although the operator did not report his actual

speed, Metrorail officials later calculated his

speed at that time to be about 45 mph.8

 (See

appendix C.) The controller radioed to the train

operator, “We understand this 111; continue on

mode 1 [automatic] operation. The reason you

have that maximum speed is because you had

one car off the platform at Rockville.”

At 10:36:40 p.m., the train operator called

the controller again and said, “I have 75/75/75,”

which indicated that his actual speed had

reached 75 mph. At 10:36:52 the controller

answered, saying to the train operator, “Roger

111. Be advised I understand you have

75/75/75.”

The Red Line radio controller stated later

that he was concerned about the train’s speed.

At 10:37:05, he called the train operator and

asked, “Has your speed dropped down at this

time, 111? You’re approaching the station.” The

train operator answered, “It’s down to 35/35.”

The Red Line radio controller told Safety

Board interviewers:

At this time I had a feeling the

system was doing what it was

supposed to do. It was slowing

the train down to make the stop

at Shady Grove. At this time, I

didn’t feel I had an emergency

 

of the physical layout of the track, will allow a train to

attain over that route segment under any circumstances).

The second readout is the automatic train supervision, or

ATS speed (labeled and sometimes referred to as the

“regulated” speed and representing the maximum speed

authorized by the main system computer for the

performance level in effect at the time). The third readout,

labeled “train” speed, displays the train’s actual speed.

8

The syslog records the time that a train enters and

leaves each track circuit. Metrorail officials used the known

length of the circuit to calculate the average speed of train

T-111 for each of the 18 blocks (ranging in length from 52

feet to 1,342 feet) between the Rockville and Shady Grove

passenger stations. (A block is a section of track of defined

limits, the use of which is governed by interlocking signals

and cab signals under control and protection of the

automatic train control system.) Because the detection

system polls the entire route system about once each

second, there may be as much as a 1-second error in

recorded block times. This imprecision can affect the

accuracy of speed calculations, particularly in very short

blocks.
6

Figure 3 – The operator’s console on both Breda and Rohr Metrorail cars is a two-part

console divided into a sloping indictor panel and a flat control panel section. The speed

control blowup illustrates the Breda configuration.
7

where I could step in and

overrule—put my job on the

line—and tell the man to go

manual.

The syslog indicated that when the train

operator reported speeds of 35/35, his train was

traveling in excess of 50 mph and was about

1,140 feet from the Shady Grove station

passenger platform. According to WMATA

speed calculations, train T-111 did not actually

slow to 35 mph until after it passed the north

end of the platform, moments before impact. At

the time train T-111 should have come to a stop

at the station platform 4-car marker, it was

actually traveling at a calculated speed of 36

mph. The train proceeded on track 2, passed the

A15-38 signal before the interlocking9

 just north

of the station, and struck the gap train

approximately 470 feet from the end of the

passenger platform. (See figure 4.) Safety Board

deceleration calculations indicated that train T111 was traveling between 22 and 29 mph when

it struck the standing train.

At 10:40:15 p.m., the Shady Grove terminal

supervisor, whose office is located at the north

end of the station platform, reported to the OCC

that a collision had occurred between train T111 and the standing gap train. The OCC

supervisor reported the accident to the general

superintendent for rail transportation, who in

turn relayed the information to the deputy

general manager for operations.

Upon learning of the accident, the general

superintendent for rail transportation and the

deputy general manager for operations each

departed for the accident scene. The general

superintendent for rail transportation arrived on

scene about 11:30 p.m. He said that, after

ascertaining the status of all Metrorail

employees, he examined the trains and track,

accompanied by the general superintendent for

car maintenance and the director of quality

assurance and training, both of whom had also

 9

An interlocking is a network of track crossings

protected by signals that show a clear aspect only when an

uncontested route is available through the interlocking and

the track switches are properly lined and locked.

recently arrived on the accident scene. The

general superintendent for car maintenance

stated that he examined the rails closely and

carefully and that he saw no evidence of skid

marks.

The general superintendent for rail

transportation stated that he and the other

Metrorail officials examined the circuit breaker

panel in the operating compartment and found

that all the breakers that would normally be

sealed—including the automatic train protection

(ATP) cutout switch, which, if activated, would

have removed ATP speed protection—remained

sealed. He stated that the “mushroom” button,

which activates full emergency braking, was in

the depressed position. The general

superintendent for car maintenance stated that,

because he saw no evidence of skid marks on

the track or on the train wheels, he believed that

the mushroom button had been depressed by the

force of impact or by flying debris and not by

the train operator. This was also the opinion of

the director of engineering and operations

support, who examined the accident train later.

Injuries

The operator of train T-111 was fatally

injured. The train’s two passengers were not

injured. The gap train operator was in the

terminal block house at the end of the passenger

platform when the accident occurred; he was not

involved in the accident.

Train Damage

Car 3252, the lead car of train T-111,

sustained the most extensive damage. The shell

of the car became partially disengaged from the

frame and came to rest partially on top of the

lead car of the gap train. (See figure 5.) The

fiberglass end cowl of the car was pushed inside

the carbody, and the end underframe assembly

moved rearward10 as a unit, collapsing several

of the transverse beams aft of the unit, buckling

the floor, and upsetting passenger seats. The

 10Strictly speaking, the impact caused the front end

underframe assembly to remain stationary, or nearly so,

while inertia drove the rear of the car forward.
m

(uQ 1 % -% >

.-

al

3%I F’

.-s#

T-
9

Figure 5 – Final position of accident trains. Gap train (left) has telescoped 21 feet into

the shell of train T-111
10

operator’s compartment was completely

crushed. (See figure 6.)

Car 3191, the lead car of the gap train,

sustained a uniform crush of approximately 10

inches across the front of the car at frame level

(figure 7) and telescoped approximately 21 feet

into the lead car of train T-111. The fiberglass

cowl sustained cracking and other damage but

remained relatively intact and attached to the

shell of the body. The operator’s compartment

and interior of the car received relatively minor

damage.

The remaining cars of train T-111 and the

gap train received only minor damage. Total

estimated damages were between $2.1 and $2.6

million.11

 11“Executive Summary,” WMATA Preliminary Report

in the Matter of Collision of Train T-111 at Shady Grove,

February 9, 1996, p. 1.

Personnel Information

Train Operator -- The operator of train T-111

was 48 years old. He was hired by WMATA on

November 11, 1975, as a bus operator and was

promoted to train operator on October 29, 1995,

qualifying for that position through formal and

on-the-job training. He worked for the first time

as a train operator on November 1, 1995, on the

Green Line. He had operated trains over the Red

Line for all or part of approximately 30 duty

days prior to the accident. WMATA provided

the Safety Board with two “follow-up”

evaluation reports, dated November 6, 1995, and

November 21, 1995, made on the operator of

train T-111 by the Office of Quality Assurance

and Training. The reports included evaluations

of the operator in terms of appearance, work

equipment, ATO operation,

Figure 6 – Head end of train T-111
11

door operation, communication, and general

train operation. Both reports indicated that the

train operator satisfactorily performed all

required functions.

After being off duty on Sunday, December

31, and Monday, January 1, the train operator

reported for work on the evening shift on

Tuesday, January 2. He worked evening shifts

(from about 3:15 p.m. until about 12:15 a.m.) on

Tuesday, Wednesday, Thursday, and Friday. His

wife stated that he normally slept between 1:00

a.m. and 9 a.m. each day. The day before the

accident, the operator reported for duty at 3:24

p.m. at Brentwood Yard. He made two trips on

the Red Line between the Wheaton and Shady

Grove passenger stations during his tour of duty.

He went off duty at Brentwood Yard at 12:15

a.m. on January 6.

The train operator’s wife stated that on

January 6 her husband slept from about 1:30

a.m. until about 9:00 a.m. She stated that he

took a nap between about 11:00 a.m. and 1:45

p.m. and left for work at about 2:30 p.m.

Metrorail records indicated that he reported for

duty at Brentwood Yard at 4:02 p.m. for the run

(job assignment) designated by Metrorail as No.

505. When he reported for work, he had been

off duty for 15 hours 47 minutes and had slept

for about 10 hours 15 minutes in the preceding

24 hours.

Shortly after going on duty on January 6, the

train operator deadheaded to the Wheaton,

Maryland, passenger station and operated trains

T-108 and T-110, making one round trip

between the Wheaton and Shady Grove stations

in each train. The train operator’s next train was

T-111, with which he departed the Wheaton

station toward Shady Grove at 9:37 p.m.

OCC Radio Controller -- The radio controller

was 55 years old. He joined WMATA on June

Figure 7 -- Head end (struck end) of gap train
12

24, 1967, as a bus operator and became a train

operator in 1981. In 1984, he became utility

supervisor at Shady Grove. In 1986, he entered

the utility program for the OCC and in 1989 was

promoted to OCC supervisor (referred to in this

report as “controller”). He had worked the 10:00

p.m. to 6:00 a.m. shift “3 or 4 years,” and had

worked for the previous 6 months with the

individual who worked as the button controller

on the night of the accident.

OCC Button Controller -- The button controller

was 48 years old. He had spent his career

working with WMATA and its predecessors,

beginning on September 26, 1969, as a bus

operator, later becoming a street supervisor for

the bus company. In 1975, he entered training as

an OCC controller. He stated that he was one of

the first six controllers assigned to the newly

opened OCC in 1976. In 1978, he became an

assistant OCC superintendent. He stated that in

1984 or 1985, he wrote the procedures, duties,

and responsibilities for every position within the

OCC. He moved back into an OCC controller

position in 1985 and worked in that capacity

until assuming the position of assistant field

superintendent in 1990. He returned to the OCC

as a controller in July 1995. He stated that,

although controllers could be assigned to either

the button or radio consoles, he usually worked

the button controller assignment because he felt

more comfortable with it since he had only

recently returned to the OCC after a 5-year

absence.

Train Information

Both train T-111 and the gap train consisted

of railcars manufactured by the Italian firm of

Breda Costruzioni Ferroviarie, S.p.A., and were

among the 466 Breda cars owned by WMATA

and operated on the Metrorail system.

(WMATA also owns and operates

approximately 300 cars manufactured by Rohr.)

Each car was 75 feet long and 10 feet wide and

weighed approximately 37 tons. The cars could

seat 68 passengers each, with standing room for

an additional 119, for a total passenger capacity

of 187.

Like all cars on the Metrorail system, each

car was propelled by four traction motors

receiving power from an electrified “third rail.”

According to published technical specifications,

the cars were capable of a top speed of 75 mph

with acceleration rates ranging from 0.75 mph

per second (mph/sec) to 3 mph/sec. Service

brake deceleration rates ranged from 3 mph/sec

to 0.75 mph/sec. The cars were equipped with

emergency brakes capable of effecting a

maximum deceleration rate of 3.2 mph/sec

under normal conditions.

All Metrorail carbodies are constructed

primarily of aluminum extrusions that serve

both as structural components and as exterior

skin for the roof, side walls, and rear-end cowl.

The front-end cowl is molded fiberglass. (See

figure 8A.) The main underframe consists of

transverse aluminum beams attached to the

lower side wall extrusions (also aluminum),

which run the full length of the car and serve as

side sills. The underframe (figure 8B) does not

have a center sill that runs the entire length of

the car, but does have intercostals (short

longitudinal members) between some transverse

beams. The end underframe assembly (figure

8C) is fabricated of low-alloy, high-tensile steel

and consists of a bolster, draft sill, and angular

sill end fitted with a conventional anticlimber.

These components are welded together to form a

single unit. The end underframe assembly

bolster is attached to the side sills by mechanical

fasteners referred to as huck bolts.12 The draft

sill of the end underframe assembly is attached

to the side sills by four aluminum transverse

members (two on each side of the draft sill),

which are attached by bolts to the draft sill and

welded to the side sill. The end sills of the end

underframe assembly are bolted to the ends of

the side sills, as shown in figure 8D.

Train T-111 -- Train T-111 consisted of two

“married” pairs13 of Breda cars: 3252 and 3253,

 12Huck bolts refers to any of a variety of two-piece,

pull-type lock bolts, similar in function to rivets, that are

used to connect or secure structural components.

13Married pairs refers to a permanently coupled twocar unit with an operating compartment at each end.
13

Figure 8 – (A) Typical WMATA Metrorail carbody structure; (B) Underframe of Breda

Metrorail car; (C) End underframe assembly; (D) Attachment of side sill to end sill of

underframe

.
14

placed in revenue service on December 10,

1987; and 3192 and 3193, placed in revenue

service on October 10, 1986. According to

Metrorail records, a daily safety test was

performed on train T-111 on the day of the

accident, and no exceptions were noted.

The train operator who operated the same

consist as train T-111 before it was turned over

to the accident operator stated that he first took

possession of the train at 4:53 p.m. at

Brentwood Yard. He operated from Brentwood

Yard to Wheaton on the Red Line, then used the

same consist for two round trips between

Wheaton and Shady Grove. He stated that he did

not experience any problems with the consist.

He operated in mode 1 at all times during these

two round trips and did not report overrunning

any stations.

Gap Train -- The gap train consisted of three

married pairs of Breda cars: 3164 and 3165,

placed in revenue service on June 13, 1986;

3120 and 3121, placed in revenue service on

October 5, 1985; and 3190 and 3191, placed in

revenue service on October 3, 1986.

Site Description

The Shady Grove passenger station is a

terminus and a final passenger station on the

Red Line. The passenger station is located

adjacent to a Metrorail yard and a railcar service

inspection shop that performs running

maintenance on cars operating on the Red Line.

The collision occurred on ballasted track

470 feet north of the north end of the Shady

Grove passenger station platform. The track in

the accident area consists of two main tracks,

designated as track No. 1 (inbound, or toward

Washington, D.C.) and track No. 2 (outbound,

or away from Washington, D.C.), with a third

rail for each track. The tracks are constructed of

115-pound continuous welded rail and are

situated in generally a north-south direction.

The track approaching the station is tangent

(straight) with a 0.35 percent descending grade.

The track remains tangent until just north of the

station where it curves to the left, then

immediately and equally to the right at the south

end of the first interlocking.

The passenger platform is 600 feet long.

Interlockings are located on either side of the

station. The south interlocking on No. 2 track is

428 feet long and is, at its closest point, 52 feet

from the south end of the station platform. The

A15-08 signal protects northbound movements.

The interlocking north of the station is 223 feet

long and is, at its closest point, 213 feet from the

north end of the station platform. Signal A15-38

protects northbound movements through the

interlocking.

Operations Information

The WMATA Metrorail system began

serving the Washington, D.C., metropolitan area

in 1976. The system consists of about 89 miles

of track and 74 passenger stations, about onehalf of which are above ground. The system

comprises five separate, intersecting “lines,”

designated Red, Blue, Green, Yellow, and

Orange, that connect the Maryland and Virginia

suburbs with the District of Columbia. (See

figure 9.)

The Red Line operates between the

Wheaton passenger station in Wheaton,

Maryland, and the Shady Grove passenger

station near Gaithersburg, Maryland, by way of

downtown Washington, D.C. The 30.38-mile

Red Line serves a total of 25 stations (including

Wheaton and Shady Grove) in Maryland and the

District of Columbia. About one-half of the Red

Line stations are above ground. Under normal

conditions, a train requires about 58 minutes to

completely traverse the Red Line and service all

25 stations. The distance between the Rockville

and Shady Grove passenger stations is 2.68

miles.

Operations Control Center (OCC) -- The Metrorail

OCC, located in the Jackson Graham Building at

600 Fifth Street, N.W., Washington, D.C.,

serves as the control center for the Metrorail

system. The OCC is responsible for providing

positive control over all station activities, train

movements, and subsystems (power, automatic

train control, automatic fare collection, and

communications) necessary for the efficient

movement of passengers. The OCC controls all

revenue activities, including radio
15

Figure 9 – Schematic representation of the Washington, D.C., Metrorail system with

selected locations identified
16

communications, interlocking operations, gap

train usage, coordination of troubleshooting

activities, train and service recovery, and any

other functions affecting passenger movement

on trains. The OCC monitors activities in

passenger stations through communication with

station personnel. The OCC also manages all

emergency situations in accordance with the

established rules and procedures, contacting

fire, police, and medical services as required.14

On the night of the accident, the OCC was also

responsible for preparing for and reacting to the

winter storm that was moving into the area. This

included providing for overnight storage of

trains in tunnels or other protected locations.

OCC Staffing -- On the day of the accident, the

OCC evening shift started at 10:00 p.m. Staffing

included the OCC superintendent assisted by a

utility assistant superintendent (who also served

as controller on the Green Line); button and

radio supervisors (controllers) for the Red Line;

button and radio controllers for the Blue/Orange

Lines; and a controller for the Yellow Line.

Signal and Train Control Information

Train operations on the Red Line segment

between the Grosvenor and Shady Grove

stations are governed by a traffic control system

that controls train movements in both directions

on two main tracks. The system employs

General Railway Signal (GRS) type AW light

signals, located at interlockings only, and GRS

Model 55E electric switch machines. Train

speeds are controlled by audio frequency (AF)

track circuits. Interlockings are operated

remotely from a control panel in Washington,

D.C.

Each Metrorail mainline route is divided

into blocks from the terminal station at one end

to the terminal station at the other end. Each

block is checked for train occupancy by means

of AF track circuits. Tuned impedance devices

known as WEE-Z bonds provide block

separation. These WEE-Z bonds inject into the

track coded AF signals that detect the presence

 14WMATA Department of Operations Organization

Handbook, pp. 71-72.

of a train in the block and automatically transmit

limiting and regulated speeds to passing trains.

There is generally one track circuit per block,

with WEE-Z bonds located at each end of each

track circuit.

Automatic Train Control

The WMATA Metrorail system operates

under an ATC system that was designed to

allow for fully automated train operations

requiring very little direct involvement by train

operators. The degree of automation is partially

determined through the use of the following

three operating modes:15

Mode 1 (automatic): Normal train

functions, including acceleration, speed,

and braking, are controlled by the ATC

system, with the operator responsible

for monitoring console indicators and

track conditions.

Mode 2 (manual with speed protection):

Train acceleration and braking are

manually controlled by the train

operator, with overspeed protection

provided by the ATP subsystem. (In this

report, all references to manual train

operation refer to mode 2.)

Mode 3 (manual with automatic train

protection cutout): All train operations

are controlled by the operator, with no

overspeed protection. This operating

mode is only used when malfunctioning

equipment makes mode 1 or 2 operation

impossible.

The ATC system consists of three

subsystems:16

Automatic Train Protection: The ATP

subsystem was designed to enforce safe

operation of the system. It imposes

speed limits to maintain train separation

and allow for safe stopping distances

 15WMATA Department of Operations Organization

Handbook, p. 46.

16Elements of Railway Signaling, June 1979, General

Railway Signal, pp. 1202-1206, and the Metrorail Safety

Rules and Procedures Handbook.
17

between trains, ensures safe door

operations, and provides control of

interlockings. The first speed readout on

the train operator’s console indicates the

ATP (or “limiting,” or “design”) speed.

The system was designed never to allow

trains to exceed the ATP speed in

normal operation.

Automatic Train Supervision (ATS): The

ATS subsystem was designed to

monitor system status and provide the

appropriate controls to maintain

efficient train operation and scheduling.

It is through the ATS subsystem that the

OCC controller is able to set or change

performance levels for trains across the

Metrorail system.

Automatic Train Operation (ATO): The

ATO subsystem performs basic train

operating functions, including starting

trains and accelerating to running speed,

maintaining en route speed, and

controlling train stopping and

positioning at passenger stations.

Although the ATO subsystem was

designed to allow totally automatic

traffic regulation by automatically

selecting performance levels,

automatically adjusting dwell times at

stations, and providing fully automatic

door operation,17 at the time of the

accident, that function was not enabled

on the Metrorail system. (In this report,

to avoid confusion, ATC is used to refer

to all elements of the Metrorail

automated train control system,

including its ATO aspects.)

Train-Wayside Communication (TWC) -- The

TWC system provides 2-way communication

between the train and the wayside at station

platforms. TWC signals are received on board

the train from the rails by ATP receiver coils

mounted on the cab end of each car ahead of the

first axle. TWC signals are transmitted to the

 17Under current Metrorail operating procedures, train

doors open automatically when a train is properly berthed

in a station, but the doors are closed by the operator.

rails from the train by a 3- by 4-foot transmit

loop mounted beneath the front of the train’s

lead car. Communication between the train and

the wayside begins as a train approaches a

station and continues until the train leaves the

station platform.

The TWC system makes automatic station

stopping possible through use of an “outer

marker” (in the form of tuned coils located

between the rails) that signals to a train that it is

approaching a station. Except in locations where

the distance between stations will not allow it,

the outer marker is 2,700 feet from the station

platform center line. Other markers are located

1,200 feet, 484 feet, and 160 feet from the

platform center line. After the train passes the

outer marker, ATC equipment gradually lowers

the speed of a train, bringing it ultimately to

zero at a predetermined target stopping point.

Once the train is properly positioned along

the station platform, carborne equipment

transmits train-berthed and station check signals

to the TWC devices. Reception of these signals

causes the WEE-Z bond located at the leaving

end of the station platform to stop transmitting

speed commands to the train. Once the speed

commands are removed, ensuring that the train

will not start up, the WEE-Z bonds at either end

of the station block transmit the “doors open”

command. If the train is not acceptably aligned

with the station platform, it receives the open

door transmission from only one of these two

bonds, and the doors will not open. At the end

of a predetermined time, the doors open

command transmission is stopped, and speed

command transmissions are resumed. When the

carborne equipment reports that the doors are

closed and that the train is ready to depart, the

WEE-Z bonds transmit to the train the ATS

speed limit and acceleration rate that will be in

effect as the train proceeds to the next station.

Performance Levels -- At the time of the

accident, the ATC system used a range of

performance levels to define top speeds and

acceleration rates of Metrorail trains operating

over various route segments.18 These

 18Metrorail trains can be assigned one of 14 discrete
18

performance levels were established by

Metrorail controllers and could be altered as

necessary. Safety Board tests confirmed that, on

the segment of the rail system where the

accident occurred, performance levels could

only be transmitted to trains while the trains

were standing in or passing through passenger

stations. At the time of the accident, the

performance levels (PLs) available for

assignment to trains leaving the Rockville

station on track 2 toward the Shady Grove

station reflected the following speeds and

acceleration rates:

PL 1: 79 mph (ATP speed of 75 prevails) with

normal acceleration.

PL 2: 64 mph with normal acceleration.

PL 3: 59 mph with normal acceleration.

PL 4: 49 mph with normal acceleration.

PL 5-8: Top speeds equal to those of PLs 1-4

but with one-half the normal rate of 

acceleration.

The second of the three speed readouts (the

middle readout) on the train operator’s console

indicates the ATS speed (“regulated speed”) as

established by the performance level in effect at

the time.

According to syslog data, train T-111

entered the Rockville station operating under the

performance level 8 that had been assigned at

the Twinbrook station. At that time, a

performance level 3 (maximum speed of 59 mph

with full acceleration) was in effect at the

Rockville station, and according to the syslog,

the train was sent that performance level as it

progressed into and partially through the station.

When the train overran the station platform, the

train operator, as directed by the OCC

controller, “dropped” the “left and right [circuit]

breakers,” which kept the doors on the first car

 

ATS speeds, but only four of these are available for

assignment at any one time. These four speeds, with normal

acceleration, define performance levels 1 through 4. These

same four speeds, but with acceleration limited to one-half

the normal rate, define performance levels 4 through 8.

Because of the variation in design speeds from one route

segment to another, different performance levels could

result in the same ATS speed, or the same performance

level could result in different ATS speeds, depending on

the locations where the performance levels are in effect.

closed while he opened doors on the remainder

of the train using switches in the control cab.

The syslog showed that after train T-111

finished servicing the Rockville station and

reestablished communication with wayside

communications devices, it was (because of the

overrun) not positioned to receive transmission

of the performance level that was in effect and

therefore defaulted to performance level 1. This

set the train’s ATS speed for the next route

segment (Rockville to Shady Grove) to 75 mph,

the maximum allowed by the ATP subsystem

for that route segment.

Railcar Braking System

Metrorail cars are equipped with both

electric (dynamic19) and friction brakes. Both

brake systems incorporate an automatic

“slip/slide” wheel protection system that is

designed to prevent wheel slips when the train

accelerates, or wheel slides when the train slows

or stops. The car braking system is part of the

overall ATC system. If a train operating in

manual mode should exceed the ATP speed in a

particular block without the operator taking

action within 2 seconds to slow the train, the

ATC system activates the train braking system

automatically. The ATC system also activates

automatic train braking by using the ATP

subsystem and TWC devices to transmit to

trains reduced speed commands at certain

points—such as curves and station

approaches—along a route. The on-board

braking computers react to these lowered speed

commands by reducing propulsion or by

applying train brakes as necessary.

Braking may be applied at any one of five

standard levels or one emergency level (full

braking). The five standard braking levels are

 19Under propulsion, Metrorail trains are driven by

electric traction motors that receive electricity from an

adjacent third rail. Under “dynamic” braking, the traction

motors are converted to electric generators that supply

electricity back to the third rail. This electrical “load” on

the traction motor/generator acts to slow the motor shaft

rotation, which results in a braking action being applied to

the train wheels.
19

designed to achieve the following deceleration

rates:

B1: 0.75 mph/sec ± 0.1 mph/sec

B2: 1.65 mph/sec ± 0.1 mph/sec

B3: 2.00 mph/sec ± 0.1 mph/sec

B4: 2.20 mph/sec ± 0.1 mph/sec

B5: 3.00 mph/sec ± 0.2 mph/sec

Emerg.: 3.20 mph/sec ± 0.2 mph/sec

Braking characteristics also include a

“speed taper” that occurs between 50 and 75

mph. The specification requires that at 75 mph

train speed, the braking system achieve 75

percent of the B2, B3, B4, or B5 commanded

rate. At 50 mph, the specifications require the

braking system to achieve 100 percent of the

commanded rate.

In a typical braking scenario, dynamic

braking is applied first. When the train’s speed

drops to the point that dynamic braking is no

longer effective, the friction brakes take over

and dynamic braking is terminated. The friction

brakes on each truck are controlled

independently of those on the other trucks. The

specifications require that the friction brakes be

fail-safe in design, construction, and operation.

According to the specifications, no failure or

series of related failures of the brake equipment

should cause the resultant brake force applied to

be less than 75 percent of the braking force

commanded by full service (B4) braking. If a

brake failure is detected, the system is designed

to prevent the release of the brakes or the

application of power after the next stop. There is

no mechanism that allows the ATC system to

verify that the train is achieving the desired

braking rate.

According to a February 14, 1996,

WMATA memorandum, (appendix D) the

Metrorail ATC block design was based on the

availability of at least 75 percent of full service

(B4) braking, which is equivalent to a

deceleration rate of 1.65 mph/sec. Although a

margin of safety was built into the design, the

memorandum states: “If the effective brake rate

of the train falls below this level [1.65 mph/sec],

then other measures must be taken to assure safe

operation.”

The automatic slip/slide system is an

integral part of the train’s braking system. The

technical specifications state that the slip/slide

system should be able to detect all wheel slips

or slides, whether random or synchronous. If the

available adhesion will not support the tractive

effort during acceleration or the braking effort

during deceleration, the slip/slide system should

adjust (alternately increase and decrease)

propulsion or brake application to eliminate the

slip or slide.

Brake control and wheel slip/slide

protection for the Breda 2000- and 3000-series

cars is provided by an H-1 electronic unit

designed for WMATA by Westinghouse Air

Brake Company (WABCO). The H-1 unit

consists of a chassis, power supplies, a

motherboard, two input/output (I/O) boards, and

two central processing unit (CPU) boards. The

CPU boards are based on Intel’s 8080A

microprocessor running at 2 MHz with 16K of

EPROM20

 space.

The H-1 unit contains a power knockout

feature that inhibits the propulsion system

tractive effort if a wheel slip is detected from

either the front or rear truck during acceleration,

and it eliminates dynamic braking when a wheel

slide is detected during deceleration. The

slip/slide system also relies on valves that can

be used to reduce brake cylinder pressure at

each truck if so required by the slip/slide

system.

The slip/slide system is designed to operate

under all braking commands except an

emergency brake application initiated by the

operator’s mushroom button. The system is

expected to prevent flat spots and other damage

to the wheel treads under all adhesion

conditions at all speeds in propulsion, and at all

speeds above 5 mph in braking, provided that

the coefficient of sliding friction exceeds 3

percent.

 20Erasable programmable read-only memory. On

Metrorail cars, EPROM modules hold the computer

program that activates and controls the slip/slide system.
20

According to WMATA specifications for

the slip/slide system:

The efficiency of the wheel

slip-slide system shall be at

least 80% during braking at all

speeds above 5 mph and shall

exceed 60% at speeds below 5

mph, for all levels of available

adhesion above 5% (equivalent

to an acceleration rate of

approximately 1.1 mphps).

Efficiency is defined as the

average car deceleration or

acceleration rate (mphps)

expressed as a percentage of the

maximum rate which the

available adhesion is capable of

supporting.

Car acceptance test documents provided by

WMATA confirm that Metrorail cars of the type

involved in the accident met the slip/slide

braking efficiency specification at the time they

were added to the Metrorail fleet. In other

words, in conditions providing at least 5 percent

available adhesion, the slip/slide braking system

was able to achieve a minimum brake rate of

0.88 mph/sec (80 percent of 1.1 mph/sec).

Safety Board engineers calculated the

deceleration rate of the accident train to be

between approximately 1.055 and 1.136

mph/sec.

Wheel Flats and Tests of the Slip/Slide

System

Wheel flats21

 are a common occurrence

among railcars, and Metrorail cars are no

exception. (See table 1 for a weekly summary

report of wheel flats occurring between October

1995 and January 1996.) Metrorail records

indicated, however, that an unusually high

number of wheel flats began to be reported on

November 11, 1995, and that this exceptionally

 21Wheel flat refers to a wheel that has either

developed a flat spot or gone “out of round” as a result of

being dragged along the rail head. A wheel flat causes

impact to the rail head, which, if severe enough, can cause

the wheel or related components to fail, or can result in a

broken rail and/or derailment. Wheel flats often result from

locked or misapplied brakes.

high rate of reports continued through

November 14, 1995.

According to a November 14, 1995, briefing

paper prepared by the WMATA Quality

Assurance Branch, the number of wheel flats

occurring between November 11 and November

14, 1995, exceeded the total number of flats for

the entire month of November 1994. The

briefing paper stated that the branch’s car

maintenance department was collecting and

preparing to examine samples of track residue

taken from areas where wheel flat occurrences

had been especially high. It stated that Quality

Assurance Branch employees had also made

observations on board trains on November 14

but had found no reason for the increase in flats.

The paper highlighted the question of whether

operating trains in automatic mode rather than

manual would result in fewer flats and

recommended that the Vehicle Engineering

Branch of the Office of Engineering and

Operations Support evaluate the braking

characteristics of each fleet (series of cars) to

determine whether stopping profiles were

different in automatic and manual modes. The

paper concluded by highlighting other variables

for review, including rail alloys in use in highincidence areas, wheels from a different

manufacturer that had been introduced into the

system during the previous 6 months, and

possible track contamination due to gearbox oil

leaks.

On November 15, 1995, the Metrorail

Vehicle Engineering Branch prepared a

memorandum, subject “Rail Car Wheel Flats,”

for the director of engineering and operations

support. That memorandum stated that the

Vehicle Engineering Branch had conducted an

investigation into the large number of wheel

flats that had recently been experienced and had

concluded that, since “the cars were being

operated in manual at the time,” the flats were

operator-induced. The memorandum recommended that, in light of these findings, manual

operations during winter season storms be

curtailed on the Metrorail system and ATC

operations be made standard. The memorandum

suggested that such a change could be

implemented on selected areas of the Metrorail
21

system initially, then expanded if it helped

eliminate or substantially reduce wheel flats.

The director of engineering and operations

support stated that he received this memorandum and considered its recommendation. He

stated that, because he thought more testing was

needed before a firm conclusion could be drawn

regarding a cause of the increase in wheel flats,

he did not forward the recommendation to

WMATA’s top management. He stated that he

was not aware until some weeks later that the

use of mode 2 (manual) as a standard operating

mode, had, in fact, been curtailed across the

Metrorail system effective November 17.

A total of 77 flat wheel incidents, 47 percent

of the total for the full month of November,

occurred between November 11 and November

14, 1995. These 77 events represent 61 percent

of the flat wheel incidents occurring between

November 1 and November 17 (the date of the

change to all-automatic operation). (See figure

10.)

According to climatological data provided

by the National Weather Service, 2.47 inches of

precipitation fell at Washington National

Airport from November 11 through 14, 1995,

with ice pellets reported on November 11. The

precipitation recorded during this 4-day period

was more than half (52 percent) of the total

November precipitation of 4.77 inches.

On November 17, 1995, WMATA engineers

began developing test equipment and methods to

be used in a series of tests of the slip/slide wheel

protection system. The purpose of these tests

was to identify the cause of the high incidence

of wheel flats occurring between November 11

and November 14. The Safety Board asked for

and received a chronology of that testing,

summarized as follows:

Table 1 – Wheel flat summary

Week

Ending

Total

Flat

Car Series

Date Wheels 1000 2000 3000 4000

10/07 8 6 - 2 -

10/14 5 2 - 2 1

10/21 7 1 - 5 1

10/28 8 2 1 3 2

11/04 21 6 2 10 3

11/11 33 11 7 14 1

11/18 76 40 5 27 4

11/25 22 6 2 10 4

12/02 21 7 3 7 4

12/09 10 3 2 2 3

12/16 17 4 2 9 2

12/23 19 12 1 6 -

12/30 3 1 - 2 -

01/06/96 6 2 1 3 -
22

On November 15, 1995, a WMATA

meeting was held to discuss the large number of

wheel flats the system had recently experienced.

Plans were developed for both static and

dynamic tests to evaluate railcar braking

response with respect to wheel protection. On

December 4, 1995, a 3000-series car was

dynamically tested for wheel protection. One

station stopping test with the train operating

under ATC resulted in a long stop, but no wheel

flats.

On December 6, 1995, a 4000-series car was

dynamically tested. One ATC station stopping

test caused a long stop, but no wheel flats. On

December 12, 1995, WMATA officials met with

representatives from WABCO to discuss the

need to improve the operation of the slip/slide

equipment to reduce the number of wheel flats.

WABCO was informed of the long station stop

that occurred during testing on December 4. On

December 20, 1995, WMATA received from

LTK Engineering Services previously requested

slip/slide qualification test charts for 2000-series

cars. But according to WABCO, WMATA

directed WABCO only to improve the slip/slide

equipment in order to reduce the number of

wheel flats being experienced. On December 21,

1995, WABCO responded with three options for

upgrading the slip/slide control system on the

2000- and 3000-series cars.

These options were being evaluated when

the accident occurred on January 6, 1996. On

January 9, 1996, WMATA reviewed the test

data to determine if there was any correlation

between the test results and the accident

scenario. It was determined that the deceleration

rates exhibited by the trains experiencing ATC

station overruns during the WMATA tests were

comparable to the deceleration rate of the

accident train. The WMATA deputy general

manager for operations called WABCO for

assistance. On January 15, 1996, WABCO

personnel arrived for brake testing and

improvement.

WMATA tests conducted on January 16 and

17, 1996, showed that the effective braking

deceleration rates achieved by the 3000-series

cars during slip/slide operation was lower than

the braking rate used to design the ATC block

signaling system. Specifically, Metrorail found

that the brake rates achieved during the tests

averaged 1.24 mph/sec in simulated wet rail

conditions, while the ATC block design was

based on minimum deceleration rates ranging

from 1.65 to 2.2 mph/sec.

0

20

40

60

80

100

120

140

160

180

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Number of Flat Wheel Incidents

Figure 10 – Flat wheel incidents occurring in 1995 and resulting in multiple wheel flats. Source: Metrorail

maintenance and reliability system (MARS) significant incident report provided at Safety Board request.
23

On January 22, WABCO delivered braking

software (EPROM) upgrade kits for Breda

2000- and 3000-series cars. WABCO informed

WMATA that the upgraded software would not

satisfy the performance requirements as defined

in the WMATA specification 2Z0065, dated

June 15, 1979. The upgraded software was

designed to improve stopping distances under

low-adhesion conditions. An emergency

engineering modification instruction, signed by

the WMATA deputy general manager for

operations, was issued on January 25, 1996, and

the braking modifications were completed over

the next 2 days.

Meteorological Information

Weather sensors monitored by Surface

Systems, Inc. (SSI), were located at Shady

Grove. According to SSI data, at approximately

10:14 p.m., no precipitation was recorded. At

10:15 p.m., all four sensors indicated

precipitation. The last reading from the sensors

before the accident was about 10:33 p.m. At that

time, sensor number two at the Shady Grove

Metrorail service and inspection shop indicated

that precipitation was falling; air temperature

was 27 °F, surface temperature was 26 °F, and

winds were calm.

Medical and Pathological Information

Rescue workers found the operator in a

semi-sitting position in the center aisle next to

the control cab, with his body perpendicular to

the longitudinal axis of the train. Death was

attributed to multiple fractures of the skull and

crushing chest injuries.

The train operator had a history of chronic

pancreatitis and had been diagnosed as a

controlled, non-insulin-dependent diabetic. He

also complained of chronic back pain.

According to the train operator’s medical

records, he had used Tylenol 3 (acetaminophen

with codeine) periodically over a period of at

least 18 months prior to the accident for the

treatment of his back pain. WMATA medical

records for the train operator disclosed that he

had been told on May 5, 1994, to take Tylenol 3

only after work as needed for back pain. During

this time, he was not working as a train operator

but as a Metrorail station manager. On

December 29, 1994, the train operator reported

to the WMATA medical office that he had been

off Tylenol 3 for 6 months but that he had begun

taking the medication again because of the

recurrence of back pain. A WMATA physician

told the train operator to minimize his intake of

Tylenol 3 while working. According to the

medical records, the train operator was told that

he should “(try to do without it) – if he was to

take Tylenol 3, take 1/3 of this tab along with 2

Advil on a full stomach.”

Before the train operator entered the train

operator training program, he was, on July 24,

1995, given a medical examination by the

WMATA medical office. A drug test that was

administered in conjunction with this

examination was negative for drugs, including

morphine. The examining physician noted the

train operator’s prior ailments and the drugs that

had been prescribed for their control; however,

no mention was made in the medical records of

the operator’s prior use of Tylenol 3 or Advil.

A small bag containing some of the

operator’s personal belongings was found at the

scene of the accident. According to police

reports, a prescription bottle in the bag

contained three Tylenol 500 mg tablets, two

Tylenol 3 tablets, four Advil caplets, two

Pancrease capsules, and one medication that was

not identified beyond the manufacturer’s name

(Mylan).

The Maryland State medical examiner’s

office reported the results of laboratory testing

of blood and urine specimens from the deceased

train operator. The medical examiner’s test

results for blood were negative for alcohol,

phenylpropanolamine and codeine. The results

were positive for acetaminophen, morphine (a

metabolite of codeine), chlorpheniramine, dextromethorphan, and pseudoephedrine. Carbon

monoxide was normal. The medical examiner’s

test results for urine were positive for acetaminophen, codeine, morphine, chlorpheniramine, dextromethorphan, pseudoephedrine,

and phenylpropanolamine. Tests for other drugs

were negative.
24

Portions of the train operator’s specimens

were sent by the Safety Board to the Center for

Human Toxicology (CHT) in Salt Lake City,

Utah, for additional analysis. The CHT test

results for blood and urine were positive for

codeine and morphine, and negative for

diazapam (valium).

Acetaminophen and codeine are found in

Tylenol 3. Morphine is a metabolite of codeine,

and the four remaining substances are found

combined in several over-the-counter multiplesymptom cold medications. Ingested

medications were found to be at therapeutic

dosage levels, and the morphine was at a

metabolized level.

Postaccident alcohol and drug tests were

administered within 12 hours of the accident to

the Red Line radio controller and the Shady

Grove terminal supervisor who were on duty at

the time of the accident. Analysis of all

specimens from both individuals was negative

for alcohol or other drugs.

Wreckage

The impact sustained by the lead car (3252)

of Train T-111 sheared the huck bolt fasteners

attaching the bolster to the side sills, broke the

welds attaching the transverse members of the

draft sill to the side sill, and sheared off the ends

of the side sill. The ends of the side sills

remained attached to the front end sill. The side

sills, once free of the end underframe assembly,

moved outward and allowed the end underframe

assembly to move rearward as a unit relative to

the body shell. The lead car of the gap train

telescoped approximately 21 feet into car 3252.

On the lead car (3191) of the gap train,

several of the huck bolts attaching the end

underframe bolster to the side sills sheared, and

the welds attaching the transverse members of

draft sill to the side sill failed catastrophically.

The ends of the side sills at the attachment to

the end sill cracked but did not fail as they did

on car 3252.

Emergency Response

At the time of the accident, the gap train

operator and the Shady Grove terminal

supervisor were inside the terminal block house

at the end of the station platform. The gap train

operator stated in Safety Board interviews that

he heard the noise of the collision and

immediately ran outside to the rear of train T111. He stated that he radioed the yard tower to

try to get third-rail power down. He said he

entered the rear of train T-111 and found two

male passengers who told him they were not

injured. He said he then continued forward as

far as the lead car, which he could not enter

because of the damage the car had sustained in

the collision. According to audio tapes of Shady

Grove yard tower radio communications, the

gap train operator contacted the yard tower at

approximately 10:47 to report the presence of

uninjured passengers and to request that the

tower bring third-rail power down. The tower

told the gap train operator that power was

coming down but that he should leave the

passengers on board the train until medical

assistance arrived.

The assistant superintendent of rail

operations at Shady Grove, who was on duty at

the Shady Grove yard at the time of the

accident, said that within a few minutes of the

collision he went to the gap train searching for

the gap train operator, whom he believed to

have been on the gap train when the collision

occurred. When he could not find the gap train

operator, he entered the rear of train T-111. He

encountered the two passengers and,

determining that they were not injured, he asked

them to remain on the train while he went

forward to search for the T-111 train operator.

The two passengers were a 28-year-old male

physician from Miami, Florida, and a 37-yearold male with no fixed address. The physician

passenger stated that he was seated in the

forward area of the last car of the train, with his

back toward the direction of travel, and that the

other passenger was in a seat behind him (the

first seat in the car, facing away from the front

of the train). When the collision occurred, the

physician passenger was standing facing the rear

of the train, with the intention of getting off at

the Shady Grove station. He stated that the

impact threw him backward (in the direction of

travel) approximately 10 feet into the front
25

bulkhead of the car. He stated that he did not

recall any train braking or any station

announcement as the train approached the

Shady Grove station.

The physician passenger’s recollection of

events immediately after the accident was

different from that of the Metrorail personnel

who were the first on the scene. The passenger

stated that about 5 seconds after the impact, the

lights in the train went out. He said that some

time after the lights went out, several people

rushed by, but they did not attempt to enter the

car to see if any passengers were aboard. He

said that, after waiting for 15 to 30 minutes,22

during which time no one made contact with

them, he became concerned and attracted a

passerby’s attention by pounding on the car

windows.

A review of audio tapes of Red Line OCC

console radio transmissions indicated that the

Red Line controller was informed that there

were passengers on train T-111 at approximately

10:50 p.m. A computer printout from the

Montgomery County (Maryland) Department of

Fire and Rescue Emergency Communications

Center indicated that they were made aware of

the two passengers aboard train T-111 at 10:57

p.m.

The OCC reported the accident to the

Montgomery County Emergency

Communication Center (911) about 10:43 p.m.

The caller identified the location of the accident

by the street address for the Shady Grove

station. The caller did not provide the

emergency service dispatcher with the status of

third-rail power or specify the best access points

to the accident site. Using a Metrorail

emergency response reference book, the

emergency dispatcher identified the chain

marker23 for the Shady Grove station and

 22In a statement to a Montgomery County police

officer immediately after the accident, the passenger

estimated the wait time at 15 minutes. In the telephone

interview with Safety Board investigators, he estimated that

he waited 30 minutes.

23Chain markers are located at 100-ft. intervals along

Metrorail rights of way. The markers show the line, the

track number, and the distance in feet from Metro Center,

entered that number into the computer-aided

emergency dispatch system. According to the

incident commander, this caused some

firefighters to respond to the Shady Grove

station rather than to the accident site some 500

feet beyond the station. Once at the scene, the

initial engine officer advised the dispatcher of

the correct location.

Section 5.1A.25 of the Metrorail Safety

Rules and Procedures Handbook (MSRPH)

states, in part:

When it is necessary to notify

the fire department(s), the

following information shall be

provided:

a. Identification of caller...;

d. Specific location of the 

problem and the best access

points;

e. Third-rail Status.

According to a Montgomery County

Emergency Communications Center computer

printout, units were dispatched and were en

route to the accident scene at 10:45 p.m.,

arriving at the scene by 10:47 p.m. The first

emergency responders to reach the scene

entered WMATA property through the security

gate located directly west of the interlocking

closest to the north end of the Shady Grove

station. Of the units initially responding, only

one was equipped with a warning strobe and

alarm device (WSAD) that could be used to

determine the status of third-rail power.

Personnel placed this WSAD (pronounced WAHSOD) on the section of third rail that supplies

power to track 2 north of the interlocking;

Metrorail personnel provided a warning light

 

which is designated as milepost 0. Chain markers are

normally referred to by their distance designation, which is

rendered in surveyors’ notation. The approved method for

identifying locations along the Metrorail system is to

specify the number of the chain marker located nearest the

accident scene; however, the last chain marker on the

western end of the Red Line is located just south of where

the accident occurred.
26

device, which they placed on the southwest

kicker rail24 in the interlocking.

According to interviews with firefighters,

rescue operations were curtailed when it was

found that a portion of the third rail in the

accident area remained energized. (See

figure 11.) Since this section of rail lay in an

area where it could pose a potential hazard to

firefighters, the officer in charge of rescue

operations ordered all rescue workers out of the

track bed except those working inside the train.

The officer stated that at that time he was aware

that two passengers were aboard train T-111.

After determining that they were not injured, he

purposely delayed their egress until the third rail

could be confirmed to be deenergized. He added

 24A kicker rail is a short section of third rail lying

within an interlocking.

that he did not know if there were any other

passengers aboard the train when rescue efforts

were curtailed, since firefighters at that time had

not completed their search of the lead car of

train T-111.

A review of the syslog for the night of the

accident confirmed that a section of the third

rail that supplied power to track 1 remained

energized until 11:23 p.m., some 43 minutes

after the accident. This section included both the

section of third rail on the western side of the

interlocking directly in front of the gate through

which firefighters were staging their rescue

operations and the southwest kicker rail in the

interlocking itself. This section of rail is

controlled by the mainline breakers located in

breaker cubicles designated 63 and 33. The

syslog indicated that an OCC controller

attempted to shut down this section of rail from

the Red Line command console shortly after the

Figure 11 -- Looking north toward the interlocking just north of the Shady Grove passenger

station. Arrows at center indicate portions of third rail that remained energized for approximately

40 minutes after the accident. Arrow at left indicates property security gate through which rescue

workers entered the track bed.
27

accident, but he was unable to trip breaker 33.

After attempting unsuccessfully to trip the

breaker from the command console at 10:41,

10:42, and 11:22 p.m., the OCC controller

requested that Shady Grove station personnel

manually operate one of the emergency trip

switches (ETSs, also known as blue light boxes,

or BLBs) at the station platform. Metrorail

personnel complied, and about 11:23, power

was removed from the remaining energized

third-rail sections in the accident area. Prior to

this time, neither the firefighters nor Metrorail

personnel had attempted to activate any of the

ETS boxes located at or near the scene. (See

figure 12.)

Section 5.2.1 of the Metrorail MSRPH

states:

Third-rail power can be

removed for the following

reasons:

--Local police or fire

department on the right-of-way;

--Derailment or collision.

Section 5.2.6 of the Metrorail MSRPH

states:

Any employee discovering a

condition requiring emergency

removal of third rail power shall

proceed to the nearest emergency trip station and operate in

accordance with the procedures

posted on the door.

The assistant general superintendent for rail

transportation told Safety Board investigators

that, since the circuit breaker at location 33 was

successfully tripped from the ETS box at the

station platform, the inability of the OCC

controller to trip the breaker on the night of the

accident was likely due to a transient fault in the

command link between the OCC and the circuit

breaker rather than to a malfunction in the

breaker itself. The assistant general

superintendent also initially reported to the

Safety Board that breaker 33 was replaced after

the accident as part of a planned upgrade of

circuit breakers along the Metrorail system.

Subsequent Safety Board investigation

determined that there was no general upgrade of

circuit breakers in the accident area, but that

routine maintenance work may have resulted in

the swapping of circuit breakers among various

breaker locations. Because WMATA does not

associate circuit breaker serial numbers with

specific cubicle locations, WMATA engineers

could not identify and Safety Board

investigators could not test the circuit breaker

that was in place as breaker 33 on the night of

the accident.

WMATA engineers told Safety Board

investigators that there had been other instances

in which third-rail circuit breakers had

intermittently failed to respond to remote trip

commands. Often, these failures could not be

duplicated by maintenance technicians, and the

cause of the failures was never identified.

WMATA officials and engineers stated that

after the accident they experienced no further

problems remotely tripping the breaker at

location 33.

A review of Red Line console radio and

telephone communications audio tapes revealed

that the OCC controller placed a call to

Metrorail maintenance to report the problem

with the circuit breaker at 10:46 p.m. At 10:49

p.m., an OCC controller made an announcement

over the Red Line console radio that all

outbound Red Line trains would be turned back

at the Twinbrook station. At 10:55 p.m., it was

reported to the OCC over the Red Line radio

that firefighters had arrived on the scene.

Shortly following this communication, trains T113 and T-101 were given permission by the

OCC to proceed to Shady Grove from

Twinbrook. At 11:04 p.m., the Red Line console

operator was contacted by Metrorail personnel

on the scene regarding the status of third-rail

power. The Red Line controller told those

personnel that he could only confirm that power

was down on track 2 and that he did not know

the status either of track 1 or the interlocking.

At 11:08 p.m. the OCC was informed over the

Red Line radio that fire rescue workers needed

power shut off to the interlocking. The Red Line

controller replied that he could not bring down

power to that rail because he had
28

Figure 12 – Schematic representations (not to scale) of Metrorail third rail power control in the accident

area. Arrows in the lower illustration indicate third rail sections that remained energized for 43 minutes

after the accident.
29

trains inbound into the Shady Grove station. At

11:09 p.m., Metrorail personnel at the accident

scene again informed the OCC over the Red

Line console radio that the interlocking was still

energized. The OCC controller told personnel at

the scene that power to that section of track

could not be taken down from the Red Line

console. At 11:23 p.m., after trains T-101 and T113 had been allowed to enter and leave the

Shady Grove station, the OCC used the Red

Line console radio to ask that personnel at

Shady Grove station activate one of the ETS

boxes, which they did. At 11:24 p.m., it was

confirmed over the Red Line console radio that

the gaps had been hotsticked25 and that power

was down.

The Red Line controller who had tried

unsuccessfully to deenergize the third rail in the

accident area stated in a June 5, 1996,

memorandum to the Safety Board that when it

was found that one of the breakers would not

trip, Metrorail managers decided to leave power

up on track 1 in order to accommodate train

service. The assistant general superintendent for

rail transportation stated that it was WMATA

policy not to strand trains between stations

because of the risk that passengers might try to

exit these stopped trains.

The arrival and departure times of trains that

arrived at Shady Grove after the accident and

times these trains arrived and departed stations

prior to Shady Grove are shown in table 2.

Communications Between OCC and Rescue

Personnel -- Several of the firefighters who

responded to the accident stated that they

received contradictory information from

Metrorail personnel at the scene when they

asked if the third rail had been deenergized.

According to recordings of tower

communications, Metrorail personnel at the

scene contacted the yard tower on several

occasions to request that power at the accident

scene be brought down. Some of these calls took

place prior to the OCC’s being contacted by

 25Hotsticking refers to testing the third rail with a volt

probe device to see if it is energized.

Metrorail personnel at the scene regarding thirdrail power. After yard third-rail power had been

brought down, the tower operator replied to

requests from the scene by informing callers that

yard power was down but that the OCC

controlled power in the area of the accident. On

at least one occasion he warned the caller that

rescuers should hotstick the gaps before

proceeding with any work. There was no

evidence that a direct communication link was

ever established between firefighters on the

scene and OCC personnel.

Section 5 of the Montgomery County Fire

and Rescue Commission’s Metrorail standard

operating procedures is applicable to Metrorail

accidents where there is no smoke or fire. Part

5.I.d of this section states, in part:

5.I.d -- If a truck or rescue

company is first on scene, the

unit officer should establish

communications with Operations Control Center (OCC).

When reaching the kiosk or

BLB, contact OCC (dial “1970”

at Kiosk, or “0” at a BLB )....

5.I.q -- First Due Duty Officer:

Establish the primary command

post at the Kiosk or other

location with access to Metro

phones and assume

responsibilities as the Incident

Commander.

Training -- An official of Montgomery

County Fire and Rescue said that joint exercises

with WMATA on the revenue portion of the

Metrorail system are conducted between 1 a.m.

and 3 a.m. and are periodically staged near

interlockings. It was this officer’s observation

that the absence of revenue train traffic during

this time period creates an unrealistic training

environment for OCC controllers. A WMATA

official stated that Metrorail yards are also made

available for training purposes during other

hours, including during the day.

Third-rail Schematic Availability -- No third-rail

schematics, such as those that are sometimes

found in Metrorail tunnels, were posted in the

area where the accident occurred. Firefighters
30

suggested that third-rail schematics posted on

ETS boxes would have aided them in third-rail

deenergization because they would have known

how the various rail sections within the

interlocking were controlled.

Warning Strobe and Alarm Devices -- For the

purpose of rescue operations in Metrorail

accidents, certain Montgomery County Fire and

Rescue stations are equipped with WSADs,

which give both audible and visual warnings if

power is present or restored to the section of

third rail to which a WSAD is attached.

According to the standard operating procedures

of the Montgomery County Fire and Rescue

Commission, two WSADs, one for each side of

the accident location, should be delivered to the

site of a Metrorail accident. An official from

Montgomery Fire and Rescue said that, because

of cost, only certain station houses were

equipped with WSADs at the time of the

accident, and the stations that were so equipped

had only one. The initial responders to the

accident reached the scene with only one

WSAD. Another WSAD arrived after some

delay, and a third one followed still later after it

was requested by firefighters at the scene.

Accident Site Configuration/Control of Third-rail

Power -- Neither the third rail in the area where

the accident occurred nor the third-rail sections

rescuers might have crossed in order to reach

the trains could be controlled by the control

tower in the yard. The area in which the third

rail could be controlled by the yard is shown in

figure 12 to the left (north) of the south end of

the second interlocking north of the passenger

station. The third rail to the right of this point

could be deenergized only by the OCC, by the

ETS boxes located in the field, or by a short in

the third rail.

Tests and Research

On Friday, March 8, 1996, from 1:00 a.m.

until 5:00 a.m., the Safety Board conducted

sight distance and stopping tests at the accident

site. At the time of the tests, snow was falling,

winds were from the northwest at 17 mph;

relative humidity was 88 percent; and

barometric pressure was 29.80 inches. The test

trains were of the same type and length as the

accident trains.

Sight Distance Tests -- For the sight distance

tests, a test gap train was placed at the

approximate point of impact. A test T-111 train

was then operated toward the Shady Grove

passenger station on track 2 in a northward

direction, and its operator was instructed to stop

as soon as the first car of the test gap train came

into sight. The test results indicated that the

marker lights of the gap train first came into

view at 1,134 feet and were fully visible at 664

feet. (See figure 13.)

Signal System and Speed Command Tests --

Safety Board investigators tested the Metrorail

signal system and determined that, during the

test period, it functioned as designed. Safety

Board investigators conducted tests to determine

whether the speed commands transmitted to

trains under different scenarios matched the

signal design and to determine whether the

accident speed scenario could be duplicated.

The tests were performed on February 21, 1996,

between Twinbrook and Shady Grove stations.

Table 2 – Postaccident train movements in accident area

Train Twinbrook Station Rockville Station Shady Grove Station

Number Arrived Departed Arrived Departed Arrived Departed

112 10:38:05 10:40:04 10:43:38 10:45:35 10:53:36 11:00:51

113 10:53:57 10:55:25 11:01:26 11:02:33 11:09:58 11:13:14

101 11:00:04 11:01:20 11:04:54 11:06:01 11:18:13 11:21:49
31

B – View from train

properly positioned at

the station platform. 

The train visible past

the end of the station

house is standing at

the approximate

location of the

accident gap train.

A – Northbound

approach to Shady

Grove Passenger

Station

C – View as train

approaches

interlocking north of

Shady Grove station.

Figure 13
32

 The first test simulated the accident

sequence. As the test train left the first block

after the Rockville station (outbound, toward

Shady Grove), and the ATP speed increased to

its normal 75 mph, the ATS speed also became

75. The test scenario thus duplicated the

experience of train T-111 on the night of the

accident

The second test was conducted to determine

what speed command would have been received

if train T-111 had made a proper stop at the

Rockville station and had not overrun the station

platform. Under this scenario, the test train was

limited to a top speed of 59 mph between the

Rockville and Shady Grove stations.

Additional tests were conducted to

determine the effect that various signal aspects

and interlocking switch positions would have

had on the speed commands received by train T111. (See appendix E for a detailed description

of all speed command tests and test results.)

Brake Equipment Tests -- After the accident,

WMATA mechanical personnel tested the brake

equipment from the cars of train T-111. The

normal periodic inspection service brake test

procedure was performed on the friction brake

equipment of cars 3192 and 3193. The tests

indicated that all pressure readings were within

tolerance except the emergency rate, which was

high on all trucks. WMATA technicians also

removed some brake components from cars

3252 and 3253 and tested them at WMATA’s

Brentwood facility. All the components

operated properly except for an N7D valve (No.

038405) located on the rear truck of car 3253,

which had an internal air leak.

Train Stopping Distance Tests -- On March 7, 8,

and 14, 1996, Safety Board investigators

conducted stopping distance tests on the

Metrorail Red Line using a 4-car train identical

to accident train T-111 (cars 3040 and 3041 and

cars 3084 and 3085). The cars were equipped

with instrumentation that monitored and

recorded, on chart recorders, brake command

level, deceleration, brake cylinder pressure, and

speed as functions of time. Four 55-gallon

drums containing a solution of water,

windshield washer fluid, and detergent were

placed in the first and third cars of the test train.

A valve system was installed that allowed

investigators to spray this solution on the rails

ahead of the train wheels to simulate the effect

of rain or snow. The objective of the tests was to

observe train braking performance under lowadhesion track conditions similar to those

experienced on the night of the accident. (See

appendix F for results of all stopping distance

tests.)

The March 7, 1996, tests were performed on

track located between chain markers 739+00

and 783+00,26 which corresponds to a segment

of track between the Twinbrook and Rockville

passenger stations. The train was operated in

manual mode for all tests, and the solution was

sprayed on the rails. Tests were conducted at 30,

60, and 75 mph and at brake levels B2 through

B5 for each speed. One northbound run and one

southbound run were made at each speed and

brake level. Investigators obtained from

printouts the speed of the train at the point

where braking was initiated as well as the time

required to come to a complete stop. They used

this information to calculate the average

deceleration rate at each brake level. Because

the portion of the Red Line where the tests were

performed is on a grade, the northbound and

southbound values were averaged to obtain an

approximation of the deceleration at a particular

brake command on level track. (See table 3.)

Investigators conducted another series of

tests on March 8, 1996, between the Twinbrook

and Shady Grove passenger stations. The track

circuit was shunted27 at the location of the gap

train. The train was operated in both manual and

automatic modes. The liquid solution was

sprayed on the rails for four of the six tests to

induce low-adhesion conditions. Station stops

were made at Rockville and at Shady Grove, and

 26Chain marker 739+00 is the 739th marker from

Metro Center, indicating a distance of 73,900 feet. The

distance between markers 739+00 and 783+00 is thus

4,400 feet. Measuring between marker posts gives even

more precise measurements and more specific locations.

27Shunted means the two running rails were

connected electrically to simulate the presence of a train in

the block.
33

the stopping behavior of the train was observed.

The position of the train when it came to rest at

each station was recorded, and the stopping

distances were calculated and recorded.

Investigators performed the final series of

11 tests on March 14, 1996, between the

Rockville and Shady Grove passenger stations.

Again, the solution was used to create

low-adhesion conditions, and the track circuit

was shunted at the location of the gap train.

Tests were conducted in automatic and manual

modes. In all but one of the tests, the train was

assigned a performance level 1. In each case, the

train began braking at a code change point

(CCP)28 located at chain marker 918+08. The

distance from the CCP to the 4-car station stop

position on the Shady Grove platform is 2,822

feet, and the distance from the CCP to the point

of impact is 3,422 feet. The stopping distance of

the train was measured for each run. Four of the

tests were performed using the postaccidentmodified H-1 software.

For tests conducted at speeds above 60 mph,

average deceleration rates ranged from a low of

1.11 mph/sec to a high of 1.50 mph/sec. The

average stopping distances for the tests

performed at 75 mph ranged from 3,353 feet to

4,588 feet. During one test similar to the

accident scenario, the test train was operated at

72 mph in automatic mode. The train began

braking at its normal location 2,822 feet from

the four-car stopping position at the station

platform. The test train overran the station and

came to rest 955 feet past the four-car station

stop marker and 335 feet past the point at which

train T-111 struck the gap train.

Gap Train Light Bulb Tests -- The gap train

operator stated in Safety Board interviews that

the red marker lights of the gap train were

illuminated while the train stood awaiting

possible assignment. WMATA provided the

eight bulbs from the front (struck end) of the

lead car (No. 3191) of the gap train, and the

Safety Board’s Materials Laboratory Division

 28A code change point is a fixed point along a route

where WEE-Z bonds located between the rails transmit an

ATP speed change code to trains traversing that block.

examined them. The bulbs from the car were as

follows:

Two 5-inch-diameter red marker lights.

Two 6.5-inch-diameter headlights.

Two rectangular running lights.

Two rectangular marker lights.

The rectangular marker lights and running

lights were identical, except that the marker

lights had red lens covers, while the running

lights had clear lens covers. The filament in the

operator-side marker light bulb showed

evidence of hot stretching, which is consistent

with a hot filament that has been subjected to

high impact forces. The sides of the aluminum

shell on the passenger-side marker light had

been deformed onto the glass of the light bulb.

The filament in that bulb showed evidence of

hot stretching. The filament from the running

bulb on the operator side was not visibly

damaged or deformed. The glass of the

passenger-side running light bulb was loose, and

two filament pieces had broken free. No

Table 3 – Average deceleration rates

under low-adhesion conditions

Brake

Level

Speed

(mph)

Average Deceleration

(mph/sec)

B5 30 2.29

B4 30 2.27

B3 30 [Invalid test]

B2 30 1.81

B5 60 1.40

B4 60 1.50

B3 60 1.33

B2 60 1.27

B5 75 1.11

B4 75 1.18

B3 75 1.21

B2 75 1.26
34

evidence of hot stretching or other types of

deformation was noted in the filament pieces or

in the remainder of the filament still attached to

the posts.

The 5-inch-diameter red marker lights were

sealed-beam lights similar to headlights. The

filament from the operator side was intact; a

major portion of the filament from the passenger

side had broken away. Both filaments showed

evidence of hot stretching. Neither of the

headlight filaments showed any evidence of

damage or deformation.

Train T-111 Inspection Test for Wheel Flats --

WMATA’s mechanical department inspected all

wheels on cars 3252, 3253, 3193 and 3192 and

reported that it found no evidence of flats on

any of the wheels. Metrorail technicians listened

to the cars as they were moved from the

accident site to the shop and reported that they

heard no sound of flats during the move.

Other Information

Oversight of MetrorailError! Bookmark not defined. -

- The Washington Metropolitan Area Transit

Authority was established in 1967 as an

instrumentality of the States of Maryland and

Virginia and the District of Columbia to plan,

finance, construct, and operate a comprehensive

mass transit system for the Washington

metropolitan area. The authority is governed by

a board of directors that comprises two members

from each of the three jurisdictions. The

chairperson of the board is chosen by and from

the board membership. The board of directors

does not play a direct role in day-to-day

operations of the Metrorail or Metrobus

systems, although it may promulgate regulations

for the safety of the public and WMATA

employees.

WMATA is a member of the American

Public Transit Association (APTA) and receives

periodic APTA safety audits. These audits,

which are provided as a service to APTA

members, cover all elements of the safety

program. The most recent APTA audit of

WMATA was conducted between December 2-

15, 1993, with a follow-up audit in June 1995.

In its audit summary report, APTA stated that

“most of the essential elements of the WMATA

System Safety Program Plan were effectively

implemented.” The next APTA audit of

WMATA is scheduled for December 1996.

The Safety Board’s interest in the oversight

of rail rapid transit safety dates back more than

20 years, beginning with a Safety Board special

study (NTSB-RSS-71-1) that explored the role

of the Urban Mass Transportation

Administration (UMTA), now the Federal

Transit Administration (FTA), in developing

safe transit systems.29 Primarily in response to

safety recommendations resulting from Safety

Board investigations of a number of rapid rail

accidents during the 1970s and 1980s and the

Safety Board’s 1991 safety study addressing

oversight of rail rapid transit safety, Congress

on December 18, 1991, enacted into law the

Intermodal Surface Transportation Efficiency

Act of 1991 (P.L. 102-240), which added

Section 289 to the Federal Transit Act. This

section directed the FTA to require those States

in which a rail fixed-guideway system (such as

WMATA Metrorail) operates that is not

regulated by the Federal Railroad

Administration (FRA) to designate a State

oversight agency to be responsible for

overseeing the safety of the guideway system.

On December 27, 1995, the FTA published

its final rule, “Rail Fixed Guideway Systems;

States Safety Oversight,” in the Federal Register

 (Vol. 60, No. 248), which became effective as 

49 Code of Federal Regulations Part 659 on

January 26, 1996. The Safety Board is following

up with the 10 States and the District of

Columbia that have rail rapid transit systems to

determine what efforts are underway to address

the FTA regulatory action.30

 29For a detailed discussion of this issue, see Railroad

Accident Report--Collision Involving Two New York City

Transit Subway Trains on the Williamsburg Bridge in

Brooklyn, New York, June 5, 1995 (NTSB/RAR-96/03).

30Safety Recommendation R-91-37, issued to the 10

States and the District of Columbia on August 6, 1991, in

conjunction with the Safety Board’s 1991 safety study,

asked these States to “develop or revise, as needed, existing

programs to provide for continual and effective oversight of

rail rapid transit safety....” The recommendation remains in

an “Open--Acceptable Action” status for the States of
35

In addition to the information required from

the States of Virginia, Maryland, and the

District of Columbia, WMATA officials told

Safety Board investigators that it is responding

to the FTA final rule by proposing the

establishment of a new safety oversight entity,

to be known as the Tristate Oversight

Committee (TOC), that will prepare and monitor

adherence to a new system safety program plan.

The TOC will also have authority to conduct

safety audits, investigate Metrorail accidents,

and require that WMATA minimize, control,

correct, or eliminate hazardous conditions. The

proposed TOC will comprise six members, two

each from the Virginia Department of Rail and

Public Transportation, the Maryland

Department of Transportation, and the District

of Columbia Department of Public Works,

Office of Mass Transit. WMATA officials told

Safety Board investigators that they expect a

memorandum of understanding reflecting these

proposals to be signed by the three jurisdictions

before the end of 1996.

Management and Organizational Factors --

Several WMATA officials, including the

general manager of WMATA at the time of the

accident, provided information about the

organizational structure, decisionmaking, and

flow of important information within the

organization. The now former general manager

stated that when he arrived at WMATA, he

divided responsibilities between the deputy

general manager for operations and himself,

retaining the financial and political domains and

delegating to the deputy authority for operations

and the supporting departments and offices.

The two managers restructured their

respective departments within several months of

the general manager’s arrival at WMATA.

According to the general manager, the deputy

configured his part of WMATA to operate like a

construction company, with a military-like

hierarchy, rather than as a high-technology

transportation system. The former general

manager said that persons hired by the deputy

formed a strong inner circle of management

under the deputy, who organized his staff for

central control.

Several WMATA employees commented

during the Safety Board investigation about the

lack of communication of important information

within WMATA. According to these

individuals, information did not flow upward to

the general manager or laterally between

departments unless the deputy personally

authorized it or provided it himself. They

suggested that the only way information could

be obtained was by asking the deputy or

members of his inner circle, and only then if the

“right questions” were asked. As one example of

information isolation, neither the general

manger, nor the director of the Office of Safety

and Risk Management, nor an instructor

responsible for operator training was aware,

before the fact, of the policy change regarding

full-time automatic train operation.

The general superintendent for rail

transportation, who reported directly to the

deputy general manager for operations, did not

distinguish between the management method

used by the deputy general manager for

operations in making the decision to require

exclusive automatic train operation policy and

those management methods used routinely. The

general superintendent stated that the deputy

held regular staff meetings, at which everyone

attending had an opportunity to speak.

Management policy was then decided, and the

managers were to do their jobs by carrying out

the decisions. Once the decisions were made,

only the deputy or executive-level officials

could consider alternative actions. One midlevel manager stated that the deputy would often

seek information directly from lower-level

employees without going through the

supervisory chain of command.

Manual Versus Automatic Operation on the

Metrorail System -- The Metrorail system, before

November 1995, had rules and policies in effect

that mandated manual operation of trains under

certain conditions. Rule 3.21 of the MSRPH (as

superseded by Special Order 94-02 issued on

May 20, 1994) stated:

Mode 2 Level 1 [manual with

speed protection] shall not be

used on mainline unless
36

specifically authorized by the

Operations Control Center, or

as specified in the current

General Orders.

Rule 3.85 stated:

During inclement weather or

when visibility is limited, Class

I vehicles shall be operated in

Mode 2 level 1 in compliance

with Special Order 94-

02/Operating Rule 3.21 and

shall enter stations at a speed no

greater than 25 mph.

WMATA also established formal guidelines

and requirements for regularly scheduled

manual operation. A July 11, 1988,

memorandum from the general superintendent

for rail transportation to all train operators and

OCC personnel stated that a program would be

implemented that established once-per-week

periods of mandatory manual operation “in

order to allow Train Operators to familiarize

themselves with manual train operation.”

Beginning in 1991, the policy of scheduled

once-per-week manual operation was

supplemented by a policy requiring all trains

entering the mainline to operate in manual mode

for the first trip in the morning. A Metrorail

official stated that this policy was initiated

because the first trip each day is made after

several hours of inactivity on the system. During

this time, rails may have collected moisture or

residue, Metrorail workers may have left tools

or equipment on or near the tracks, or other

unexpected or potentially hazardous conditions

may have developed. By operating manually

during the first trip of the day, the operator was

in a better position to respond to any such

condition.

The Metrorail system also had allowed train

operators to operate in manual mode during

periods of inclement weather. The general

superintendent for rail transportation stated in

Safety Board interviews that, historically during

inclement weather, OCC controllers instructed

operators to change to manual mode, above

ground, and that to the best of his knowledge,

this had been Metrorail policy since the opening

of the system.

On November 17, 1995, the OCC

superintendent, acting in accordance with what

he said was guidance he had received from the

general superintendent for rail transportation,

issued a notice to all OCC personnel that

included the following guidance for operations

during adverse weather:

At no time will trains be

permitted to operate in a manual

mode (Mode 2, Level 1), except

in an emergency situation.

The general superintendent for rail

transportation stated that while he remembered

discussing this new policy with the OCC

superintendent, he did not remember directing

that the OCC superintendent put the policy in

writing. The general superintendent said that “it

would be a natural assumption on his part after

receiving verbal instructions to put it in writing

so there would be no mistake.” He stated that he

was not sure whether it was before or after the

accident that he saw the written notice for the

first time.

Safety Board investigators asked the general

superintendent for rail transportation whether,

before the issuance of this notice, any tests had

been done to indicate what the performance of

either the vehicles or the train operators might

be in inclement weather if operators were not

permitted to operate in manual mode. He stated:

There were a couple of

situations where we did it on a

limited basis during inclement

weather; where we would have

the rest of the system in manual,

and then try a section to see

what happened, see if we still

had overruns or whatever. But it

was a limited, undocumented

type of thing.

On November 20, 1995, the general

superintendent for rail transportation issued a

memorandum (appendix G) that restated the

existing rule to train operators, operations

supervisors, and OCC supervisors, as follows:
37

Effective immediately, by

order of this memorandum,

all Train Operators must

obtain authorization from the

Operations Control Center to

change from Mode 1 to Mode

2 operation. The only

exception is when adjusting the

train within the platform limits,

in compliance with Special

Order #94-02 (Rules 3.21 and

3.31). [Emphasis in the

original.]

This memorandum also canceled the

requirements for manual operation one day each

week and for the first trip each day, thereby

ending regularly scheduled manual operation on

the Metrorail system. The general

superintendent for rail transportation stated:

“ATO is the safest operating mode we have. All

the fail-safe systems are activated when you are

operating ATO.”

On January 4, 1996, the OCC

superintendent issued a memorandum to all

OCC personnel stating that, effective January 5,

1996, the normal performance levels would be

used at all times systemwide, except that in the

event of a station overrun in adverse weather, a

performance level of 8 would be entered for the

station where the overrun occurred.

Error! Bookmark not defined.Maximum Authorized

Speed (MAS) -- Rule 3.82 of the MSRPH states:

“Employees shall not operate rail vehicles at

speeds higher than the maximum authorized

speed.”

On August 14, 1986, as a result of a

WMATA investigation of a February 1986

incident involving the run-through of a red

signal at the Shady Grove passenger station,

WMATA’s then-general superintendent for rail

transportation issued a memorandum, subject

“Adherence to Regulated Speed,” to all rail

operating personnel. That memorandum stated:

We are currently operating

trains at a reduced level of

speed not to exceed 59 mph.

This speed limit is enforced by

the use of performance levels

which are set from OCC.

...Train Operators shall

immediately inform OCC when

their Regulated Speed exceeds

59 mph. OCC shall in turn reset

the performance level in the

affected area to insure that the

Maximum Authorized Speed

(MAS) of 59 mph is maintained

throughout the system.

In interviews with Safety Board

investigators, the individual responsible for

training Metrorail train operators stated that the

training program emphasized the 59 mph

systemwide speed restriction. She further said

that she had personally, in both formal and onthe-job training, made clear to the accident train

operator that at no time were trains to exceed 59

mph. When asked what she thought the accident

operator should have done when he received an

ATS speed readout above 59 mph, she said: “He

should have stopped the train and hit the ATO

stop and contacted Central [OCC] and let them

know that the speed was over 59 mph.” When

asked what action she thought the OCC

controller should have taken when informed that

train T-111 was showing an ATS of 75 mph, she

said, “I think they should have said, ‘Go

manual.’”

In a Safety Board interview, the general

superintendent for rail transportation was asked,

“What is the maximum authorized speed on the

Red Line?” He answered by stating:

“Supervisors are...not allowed to authorize

anything higher than 59 mph. I would have to

say 59 mph.” He was asked, “Was the maximum

authorized speed 59 mph on the Red Line on the

night of the accident?” He answered, “Yes.”

In a subsequent Safety Board interview, he

stated:

The maximum authorized speed

that could be given by Central

[OCC] would be 59 mph...but

the...[speed] in that area [the

Red Line between Rockville

and Shady Grove] by the

computer was 75 mph. So, in

that sense, 75 mph under ATO

operation was the top speed.
38

He said that, while OCC controllers were

prohibited from authorizing train operators to

exceed 59 mph, “if a train under ATP and

within the right set of circumstances as

determined by the computerized system did

exceed it, it was safe to do so.”

A restriction board located within the OCC

was used to provide information on an ongoing

basis to all OCC employees. The first entry on

this board, on the day of the accident and,

according to testimony, for several years

preceding the accident, was as follows: “59 mph

systemwide speed.” (See figure 14.)

In Safety Board interviews, both Red Line

OCC controllers on duty at the time of the

accident stated their view that the November 17,

1995, notice from the OCC superintendent that

trains would not be permitted to operate in

manual mode except in an emergency

effectively removed any absolute speed

restriction that may have been in place on the

Metrorail system. The button controller stated:

Since the [November 17, 1995]

memo came out, everybody just

says, ‘Well, [the 59 mph speed

restriction] doesn’t mean a hill

of beans anymore because of

the 75/75. We could use 75/75

for trains to pick up schedule,

with the assistant

superintendent’s permission.

The radio controller stated:

[The 59-mph maximum

authorized speed] was never

rescinded, but it says [in the

November 17, 1995,

memorandum] that no one gives

the mode 2 operation. Now, in a

way of speaking, that could

rescind that order.... Many

times when trains overrun

stations, you get 75/75, and I

want to put them in mode 2

operation, but [we’re told] ‘no

mode 2 operation on the main

line,’ which tells me...it’s OK

to do 75/75.

The Red Line radio controller was asked

whether a train operator was required to stop the

train if the ATS speed exceeded 59 mph. He

answered, “No—only if he thinks it is an unsafe

condition. If not, he calls central control and lets

us know.”

The controller stated that the memorandum

not permitting manual operation meant that a

train operator reporting an ATS speed in excess

of 59 mph would be told to remain in automatic

mode:

My option at that point [when

the T-111 train operator

reported speeds of 75/75] was

not to stop the train...I

had...asked questions before, if

a train was running 75 mph,

should we stop it and go mode

2? I was told, ‘Negative, mode 1

operation; let the train do what

it’s supposed to do.’

Safety Board investigators asked the OCC

superintendent, who was in charge of the OCC

on the evening of the accident, whether, at the

time of the accident, the maximum authorized

speed on the Metrorail system was 59 mph. He

stated:

Yes, with the exception that, if

the train had that problem like it

did, if [it overran a station

platform] or something like that,

we knew it would receive max

speed... whatever the maximum

track speed is. If it was 65-75,

you would receive that.

The OCC superintendent also said:

I understand prior to this

[accident] we have had trains

that received the 75/75/75.... I

had been informed that I could

not, and I did not, stop the

trains.... I asked the question

specifically, ‘If I have a train

running 75 mph, do we stop it,

proceed manually, or do we

allow it to continue at that rate

of speed?’ And the answer was,

‘Continue.’ And on a daily basis

at West Falls Church, we had

trains to receive that speed.
39

Figure 14 – Restriction board in Operations Control Center displaying 59 mph system

speed
40

He went on to say:

In retrospect...I would say that

the train should have been

stopped.... However, at the time

of the incident...I had 100

percent confidence in the

system.... I have wanted to

believe and have 100 percent

faith in our operating system.

The general superintendent for rail

transportation stated that, based on the way the

system was designed to work and the

information available at the time, the OCC radio

controller acted properly by directing the

accident train operator to continue in automatic

mode even though the operator reported a

regulated speed of 75 mph. He added:

Now, in hindsight, he should

[have] immediately stopped the

train because of the weather

and...[should have told] the

operator to cut down to a lower

speed—I think even less than

59, based on hindsight. But, at

the time, the system was

operating within safety

parameters, as it was set up.

In a Safety Board interview, the WMATA

deputy general manager for operations stated:

Our normal maximum

speed...is 59 mph. We have

imposed that for years to save

energy and to save the wear and

tear on equipment. So, how the

heck...[could] the train operator

and Central Control think it’s

normal to run 75 in good

weather or bad weather? That’s

a bad decision.”

He further stated:

When a train is running at 75,

even in dry weather, it indicates

there is a problem. So you must

bring that train speed back

down to the maximum speed

allowed, which is 59, or find out

what the problem is with the

train.

Station/Platform Overruns on the Metrorail System

-- The Metrorail assistant general manager for

rail service, in an April 16, 1996, memorandum

to the Safety Board, stated that Metrorail trains

experience approximately 400 to 450 station

overruns each year while making 20-25,000

station stops each day. She stated that WMATA

considers a station overrun to be unsafe only

when the train exceeds safe braking distances

and violates the ATP block design, meaning that

it enters a track circuit that could be occupied or

enters an interlocking governed by a red signal.

She further stated that in the history of Metrorail

revenue operation and prior to the accident,

there had been no known instance of a train

violating the block design while operating under

ATC.

The assistant general manager for rail

service also told Safety Board investigators that,

prior to the accident, station overruns were

considered by Metrorail management to be an

issue of passenger inconvenience rather than an

issue of safety. The OCC superintendent stated

that, while a station overrun could be both an

inconvenience and a safety issue, “more

recently, most of them are inconveniences and

not safety issues.”

Controllers on duty at the time of the Shady

Grove collision said that they heard train

operators report at least “four or five” station

overruns during the 30 minutes preceding the

accident. The graph at figure 15 plots the

number of passenger station platform overruns

(by at least one set of doors) reported month-bymonth on the Metrorail system for the years

1992 through 1995.

Of the 63 station overruns reported in

November 1995, 14 occurred between

November 1 and November 17, at which time

the notice was issued instructing OCC

controllers that they were no longer to give train

operators permission to change to manual

operation in inclement weather. Between

November 18 and November 30, an additional

49 overruns were reported. Safety Board

investigators examined local (Washington

National Airport) climatological data from the

National Weather Service for November 1995.

42

That data revealed that the metropolitan

area received a total of 3.40 inches of

precipitation between November 1 and

November 17, and 1.37 inches from November

18 through November 30.

While no electronic means was available to

determine whether overruns occurred while

trains were operating in automatic or manual

mode, operators sometimes reported this

information. According to these reports, in

November and December 1994, 60 overruns

occurred in automatic mode, with the remaining

11 either in manual mode or unreported. Of 399

overruns that occurred during 1995, 340 were

while operators were in automatic; the balance

were either in manual or unreported. A

Metrorail official stated that, because trains

were generally operated (until November 1995)

in manual mode only for the first trip in the

morning and for a portion of 1 day each week,

“it would be expected that overruns in ATO

would greatly exceed those in manual operation

based on the relative hours that operators spent

in each mode.”

Interviews with other Metrorail officials,

train operators, and OCC personnel indicated

that in cases of a platform overrun by one car

length or less, controllers would normally direct

the train operator to deenergize the circuit

breakers controlling the doors on the first car

and to service the station from the remaining

cars.

Training of OCC Controllers -- Safety Board

investigators asked OCC controllers and the

assistant general superintendent for rail

transportation to describe the nature and

frequency of any recurrent training given to

OCC controllers covering operating rules and

procedures, physical characteristics of the

Metrorail system, and emergency preparedness

and emergency response procedures. They

stated that WMATA did not provide formal

recurrent training to OCC controllers. They

noted that controllers were required to pass an

annual rules test but that WMATA offered no

formal training or other preparation for taking

the test. They said controllers failing the test the

first time could retake it a maximum of two

additional times. Controllers failing to pass the

test after three tries would be reassigned, but

Metrorail officials could cite no instance in

which this had ever happened.

Metrorail officials reported to Safety Board

investigators that WMATA had no program to

ensure that controllers remained qualified on the

physical characteristics of the route segments

for which they had responsibility. The button

controller on duty at the Red Line OCC console

at the time of the accident stated that he had not

ridden over the Red Line in “more than 10

years.” The radio controller stated that he rode

the Red Line regularly, on his own time, in

order to stay current on the physical

characteristics of the Metrorail system.

Gap Train Placement -- According to the yard

log, the gap train was brought from the Shady

Grove yard to the passenger station platform at

about 7:00 a.m. on January 6. The OCC then

gave the gap train operator permission to move

the train back north of the A15-36 signal on

track No. 2 so that it would be ready for

immediate use. There was no evidence that the

gap train was moved from the time of its

placement to the time of the accident. In Safety

Board interviews, the Metrorail assistant

superintendent of rail operations at Shady Grove

was asked about the placement of the gap train

on the same track as incoming trains. He stated:

To my knowledge, there is no

written document, but there

were verbal instructions given.

And this was about a year

ago.... [T]hey’re instructed to

keep the gap train on track 1;

they’re instructed to keep track

2 clear and let the trains from

revenue come in on track 2 and

be dispatched from track 2. If

track 2 is occupied, they’re

instructed to take the trains in

on track 1.

The terminal supervisor on duty at the

Shady Grove station at the time of the accident

stated that it was typical for the gap train to be

stored on track 2, north of the A-15-36 signal.

The terminal supervisor stated she had no direct

knowledge of the assistant superintendent’s
43

instruction regarding the gap train’s location.

She stated: “A couple of other supervisors

mentioned it in passing, but they also put the

train on track 2, so I really didn’t think...[it]

was any pressing issue.”

The Red Line radio controller, who could

see the gap train location on his OCC visual

display, said that the gap train was left on track

2 “most of the time.” The Red Line button

controller stated that the gap train at Shady

Grove was placed on track two “every

morning,” so that trains could be brought out of

the yard down track 1 toward downtown. He

said:

I know the rule, being an exassistant superintendent,

that...as soon as your line goes

up, the gap [train] is supposed

to be moved from that track

over to the other track so that in

case there is a run through or

overrun, you don’t have...[a]

situation like this incident....

Metrorail Operating Rules -- Metrorail

operations are governed by the MSRPH and by

change orders, special orders, and memoranda.

The MSRPH, the most recent edition of

which was effective June 1994 and was signed

by the WMATA general manager, could be

changed by the following methods:

Reprinting: Incorporates all changes and

constitutes a total reissue of the manual

(normally done every 2 years).

Change Orders: Permanent revisions

made by printing only those pages that

are changed or substituting them for the

outdated ones (normally done every 6

months).

Special Orders: Temporary changes

made by issuing a single revision on the

basis of expedited need and included in

the next change order or reprint

(normally done as needed.) All

employees or contractors to whom the

rules or procedures apply could suggest

changes by submitting them in writing

to the Rail Transportation Analysis and

Support Section, which would review

each suggestion to determine its

urgency. Those suggestions requiring

immediate attention would be revised

and issued as special orders under the

signature of the general superintendent

for rail transportation. If the revision has

safety implications, concurrence of the

Office of Safety would be required.

The Safety Rules and Procedures Standing

Committee could make its recommendations for

changes, corrections, additions, deletions or

other improvements to the general

superintendent for rail transportation, who

would review all recommendations and include

those approved in the next regularly scheduled

update of the manual.31

The Safety Board reviewed the process by

which the policy of manual operation in

inclement weather was changed in November

1995. Investigators determined that the

WMATA Office of Safety and Risk

Management had no role in the policy change.

The various departments reporting to the deputy

general manager for operations indicated during

Safety Board interviews that no formal meetings

were held to discuss the change in the operating

policy regarding automatic operation during

inclement weather. The WMATA Rail

Transportation Analysis and Support Section,

according to statements made in Safety Board

interviews, did not review the decision to

evaluate its appropriateness or urgency, nor did

the Safety Rules and Procedures Standing

Committee participate in the decision.

The Safety Board reviewed Metrorail

procedures for providing train operators and

OCC controllers with safety information or

written notification of changes to operating

rules, practices, or procedures. Investigators

determined that this information was usually

disseminated through several means, including

posting notices on bulletin boards at reporting

locations and terminals throughout the Metrorail

 31WMATA, Metrorail Safety Rules And Procedures

Handbook, June 1994, p. 5.
44

system and placing copies in operators’ “traps”

(mailboxes). Testimony indicated that

sometimes train operators or other operating

personnel were asked to sign for documents, but

no procedure was in place requiring train

operators to initial or sign a form to signify that

they had read and understood memoranda or

notices establishing permanent or temporary

changes to operating practices or procedures.

Similarly, no procedure was in place for

terminal supervisors, OCC supervisors and

controllers, or other operating personnel to sign

for memoranda or notices meant for them.

Event Recorders -- WMATA Metrorail cars

are not equipped with event monitors/recorders.

The Safety Board, as a result of its 1982

investigation of the only previous Metrorail fatal

accident (see “Previous Metrorail Fatal

Accident” below”), made the following safety

recommendation to WMATA:

R-82-74

Maintain the carborne monitors

on existing Metrorail cars and

require their installation on cars

presently on order. Acquire the

necessary equipment to read the

monitor tapes.

WMATA responded in a December 15,

1982, letter that it had found that the existing

carborne monitors were unreliable and that it

was working to develop a substitute recording

device. In a series of letters to the Safety Board

between 1984 and 1987, WMATA stated that it

had investigated state-of-the art monitoring

technology and, in 1987, planned to recommend

to the WMATA board of directors that it

approve proceeding with the

design/demonstration phase of the carborne

monitor program.

In an April 22, 1991, letter, WMATA told

the Safety Board that it had successfully

completed the prototype carborne monitor

development project in September 1989. The

letter stated that the WMATA board of directors

operations committee had determined that the

procurement and installation of such equipment

on the existing rail car fleet could only be done

in a cost-effective manner at the time of a major

rehabilitation, but that the procurement of new

railcars so equipped could be accomplished

economically. Based on WMATA assurance

that, with the development of a reliable carborne

monitor, a requirement for such a device would

be included in the next vehicle procurement

specification, the Safety Board classified Safety

Recommendation R-82-74 “Closed--Acceptable

Action” on June 10, 1991.

WMATA took delivery of the first of its

4000-series (Breda) cars on December 23, 1991.

These cars were contracted for in April 1989

and were not equipped with event

recorders/carborne monitoring devices.

WMATA engineers told Safety Board

investigators that the 4000-series cars were

designed and built with wiring to transmit to a

central location on the car information about

vital railcar functions and that the cars can be

retrofitted with carborne monitoring devices

once the devices become available.

WMATA is currently rehabilitating its

1000-series (Rohr) railcars, which are the oldest

cars in the Metrorail fleet. WMATA engineers

told Safety Board investigators that 266 of the

298 1000-series cars have been overhauled and

that, while the rehabilitation program includes

preparing the cars for the future installation of a

carborne monitoring system, no such devices

have been installed on any of the rehabilitated

cars.

On September 9, 1996, WMATA distributed

and solicited industry comment on a draft

specification for a new 5000 series of railcars

that includes a proposed carborne vehicle

monitoring system. The proposed monitoring

system will be capable of continuously

monitoring and recording the performance of all

vital railcar systems. It will record wayside- or

operator-initiated commands received by the

train control system and the response to those

commands in terms of train control signals. The

monitoring system will record up to 38

operating parameters, including limiting,

regulated, and actual speeds and train operating

modes. WMATA officials anticipate that the

specification will become final before the end of

1996. No date is set for the procurement of the
45

new 5000-series cars, but WMATA officials

told Safety Board investigators that they

anticipate that when the cars are placed in

revenue service they will be equipped with

state-of-the art carborne monitoring systems.

Postaccident Policy/Rule Changes -- WMATA

implemented the following policy or rule

changes after the January 6 accident:

Gap Train Placement -- On February 14,

1996, the general superintendent for rail

transportation issued a memorandum, subject

“Terminal Operations—Gap Train Placement,”

stating that gap trains at terminal stations should

be placed to provide the safest possible

operation of the terminal. The memorandum

specified that gap trains be stored on the track

opposite the one normally used for trains

arriving from the mainline and as deep as

possible in the tail track.

Maximum Speed in Inclement Weather -- On

February 2, 1996, WMATA issued Special

Order 96-02 reiterating operating rule 3.1, as

follows:

Passenger safety is the

responsibility of every

WMATA employee; however,

Train Operators have the

ultimate and final responsibility

for the safety of the passengers

on their particular trains. If any

Train Operator is instructed by

any person, regardless of rank,

title, or position, to take any

action which would adversely

affect the safety of passengers,

the operator shall stop the train,

notify OCC or the Yardmaster,

and shall not continue until

satisfied that it is safe to do so.

The special order also listed the following

procedures applicable during inclement weather:

• Train Operators must verify

reception of a regulated speed less

than or equal to 49 mph at each

platform.

• At no time during inclement weather

shall the regulated speed exceed 49

mph. If TWC communication is not

present and a train door is opened,

such as for a Brentwood platform

stop or a station overrun, the

regulated speed will be reset to the

limiting speed. If the regulated speed

exceeds 49 mph, the Train Operator

must immediately notify OCC and

shall be governed by their

instructions.

• If unable to immediately contact

OCC, the Train Operator shall

immediately stop the train and

continue attempting to contact OCC.

• OCC shall instruct Train Operators

of trains that have received a

regulated speed that exceeds 49 mph

to stop the train and to proceed in

Mode 2, Level 1 operation to the

next station.

OCC Controller Training -- WMATA

officials told Safety Board investigators that

they commenced a new training course for OCC

controllers after the accident. They stated that

this Supervisor Technical Refresher Training

Course is a 15-day course with class size limited

to two controllers at a time. The course covers

the following subject areas:

• WMATA operating rules

• Safety rules

• Troubleshooting and troubleshooting

handbook

• Car familiarization, seatwells, door

cut-out, brake cut-out, circuit

breakers

• Standard operating practices

• Simulator training

• Automatic train control

• Emergency brake applications

• Recovery procedures

• Troubleshooting console

• Circuit breakers

• Permissive block/absolute block

• Train operator procedures

• ATC car-borne subsystems

• ATC wayside systems

• Yard operations and configuration

• Decisionmaking

• Overview of Metrorail lines
46

WMATA officials said they plan to hold

annual 3-day refresher classes for controllers

beginning in 1997. These classes will cover

rules, standard operating procedures, and safety.

According to documents provided by WMATA

to the Safety Board, 18 OCC controllers had

successfully completed this training program by

September 30, 1996.

Previous Metrorail Fatal Accident – The only

previous fatal accident in the history of the

Metrorail system occurred on January 13,

1982.32 In that accident, a Blue Line train being

operated in manual mode at the Smithsonian

interlocking was unintentionally routed into a

crossover track and through a switch that was

not aligned for a crossover move. As a

supervisor at the opposite end of the train

attempted to pull the train back through the

crossover, the rear car (which had been the lead

car in the initial crossover move) derailed. Not

realizing that there had been a derailment, the

supervisor continued to attempt to pull the train

through the crossover, at which time the

derailed car stuck a reinforced concrete barrier

wall separating the two main tracks in the

subway tube. The concrete wall penetrated the

passenger compartment, killing three passengers

and injuring 25 others. As a result of its

investigation of this accident, the Safety Board

made 37 safety recommendations to WMATA.

Of those safety recommendations, 33 were

eventually classified “Closed--Acceptable

Action” or “Closed--Acceptable Alternate

Action,” and 4 were classified “Closed--

Unacceptable Action.” (See appendix H.)

The following were among the safety

recommendations the Safety Board made to

WMATA as a result of the 1982 accident:

R-82-15

Upgrade the training given to

rail transportation supervisors

and assign them the necessary

authority to effectively super-

 32Railroad Accident Report—Derailment of

Washington Metropolitan Area Transit Authority Train No.

410 at Smithsonian Interlocking, January 13, 1982

(NTSB/RAR-82-06).

vise train operators and

correctly deal with the full

range of operational situations.

(Class I, Urgent Action)

WMATA responded in a December 15,

1982, letter that it had provided refresher

training to all supervisors, had hired a

superintendent of rail transportation training,

and had contracted for a system analysis to

identify potential training deficiencies, after

which it expected to modify its training

program. In a follow-up letter of December 14,

1983, WMATA stated that a totally revised

training, retraining, and certification program

for operators, transportation supervisors, station

attendants, station supervisors, and OCC

personnel would be phased in and would be

completely in place during the first 6 months of

1984. That letter also stated that in October

1983, OCC personnel had been tested to

determine proficiency in operating rules and

standard operating procedures and that those

who were found to be less than proficient were

retrained and retested.

In an October 18, 1984, letter in response to

this recommendation, WMATA stated that the

training program for transportation supervisors

had been upgraded in several areas, including an

annual examination on the handbook of

operating rules and standard operating

procedures. In a March 18, 1985, letter,

WMATA noted that all supervisors would

attend an intensive refresher course to

commence in April 1985, after which they

would undergo a practical requalification

examination. In its last letter in response to this

recommendation, dated October 24, 1985,

WMATA stated that it had completed its annual

refresher training and requalification program

for all transportation supervisors and that

supervisors would be recertified every 18

months. The letter went on to say that WMATA

had awarded a contract to a company that would

assist the rail training branch in upgrading the

training of several groups, including train

operators, transportation supervisors, and OCC

supervisors.
47

Based on the WMATA response, the Safety

Board classified Safety Recommendation

R-82-15 “Closed—Acceptable Action” on

October 10, 1984.

R-82-17

Amend [WMATA] standard

operating procedures to require

the Operations Control Center

to (1) require that, whenever a

train emergency which requires

evacuation is known to exist at

a location between stations, all

third-rail power circuits

between the emergency location

and the stations on each side of

that location be deenergized as

soon as all other trains have

cleared the area, and (2) to

direct the nearest qualified rail

employee to begin the timely

evacuation of passengers from

the train. (Class I, Urgent

Action)

WMATA responded by letter on December

15, 1982, stating that procedures were

established to remove third-rail power from an

affected area before passengers were permitted

on the track bed. In a follow-up letter of

December 14, 1983, WMATA acknowledged

that power removal procedures were deficient at

the time of the 1982 accident because “nonstandardized circuit breakers were installed in

parts of the system.” The letter stated that

WMATA had changed its procedures to provide

positive assurance that the breakers were

commanded open. The Safety Board, on

February 19, 1985, classified Safety

Recommendation R-82-17 “Closed--Acceptable

Action.”

R-82-63

Eliminate the practice of issuing

verbal instructions to the

Metrorail Operations Control

Center personnel which modify

or amend operating rules and

standard operating procedures.

(Class I, Urgent Action)

In a December 15, 1982, letter, WMATA

responded that it had discontinued the use of

oral instructions and had instructed OCC

personnel that “the book of rules govern until

changed by written revision or amended by

special order.” Based on this response, the

Safety Board, on July 8, 1983, classified Safety

Recommendation R-82-63 “Closed--Acceptable

Action.”
ANALYSIS

General

he accident train operator was well rested

when he reported for duty. Although he

had been on duty for about 6 1/2 hours at

the time of the accident, he was completing the

first half of only his third round-trip of his duty

day. The two OCC Red Line controllers were

working their regularly scheduled shift and had

been on duty for less than 45 minutes when the

accident occurred. The Safety Board therefore

concludes that fatigue was not a factor in this

accident.

Safety Board investigators tested the

Metrorail signal system, the track wayside

communications devices, and the electronic

command systems related to automatic train

control and determined that these systems

worked as designed during the accident

sequence. The Safety Board therefore concludes

that track and signal operations were not causal

or contributing factors in this accident.

The Accident

The accident sequence began when train T111, operating in automatic mode, overran the

Rockville passenger station by one car and the

OCC controller instructed the train operator to

service the station from the second, third, and

fourth cars. Under the design of the ATC

system, opening the doors caused the train to

lose, temporarily, the performance level—and

thus the speed limitation—that was assigned to

it. Under normal circumstances, the ATC system

would have reestablished the train’s

performance level, with a top speed of 59 mph,

once the doors were closed and train was ready

to depart. But because the first car of train T111 was outside the station limits, the train did

not receive the signal (performance level 3) for

the reduced speed (59 mph), and the system

defaulted to 75 mph (performance level 1), the

highest speed available for the next route

segment.

The train operator recognized that the 75

mph speed was too high, and he called the OCC

almost immediately to report it. The OCC

controller also recognized that the 75 mph speed

was problematic. At that point, both the train

operator and the OCC controller had time to

take action to stop the train, change to manual

mode, and defuse a hazardous situation. But

neither the train operator nor the OCC controller

was aware that, under the conditions of high

train speed and low rail adhesion that existed at

the time, the braking system of train T-111 was

incapable of stopping the train within the

distance available. Thus, neither of them

recognized the full extent of the hazard, and

largely as a result of the inflexibility of

WMATA’s management policies and practices,

neither the train operator nor the OCC controller

was willing to take independent action absent

clear evidence of immediate danger. The train

was thus allowed to continue to operate in

automatic mode at above-normal speed on

known slippery rails toward a location where a

significant station overrun could result in a

collision with another train.

After the accident, emergency responders

arrived at the accident site quickly, but they

failed to establish a direct communications link

with the Metrorail OCC. The result was a series

of misunderstandings that impeded rescue

efforts. Rescue efforts were also hampered by

the failure of the OCC, immediately upon being

notified of the accident, to turn off third-rail

power in the accident area. Had the accident

happened at a time when more passengers were

aboard the train, these failures could have

seriously affected survivability.

In its investigation of this accident the

Safety Board identified the following safety

issues:

• Adequacy and appropriateness of

WMATA methods of management,

decisionmaking, and communication;

T
49

• Safety implications of the decision to

eliminate manual train operation on

the Metrorail system;

• Effectiveness of using performance

levels to control train speed;

• Compatibility between railcar

braking performance and design of

the Metrorail ATC system; and

• Adequacy of WMATA and

Montgomery County emergency

response procedures.

Although Safety Board investigators

identified WMATA management,

decisionmaking, and communication as a

separate safety issue, the management style and

processes employed by those at the top levels of

the WMATA management were reflected in

several of the other safety issues and in a

number of the corollary issues examined as part

of this investigation. Those corollary issues

include performance of OCC controllers and the

train operator during the accident sequence,

placement of gap trains at Metrorail terminals,

adherence to Metrorail rule-change procedures,

establishment of maximum authorized speeds on

the Metrorail system, and reliance on oral

instructions. Those issues are discussed in detail

in this analysis, as are the issues of the absence

of event recorders on Metrorail cars, the

crashworthiness of Metrorail cars, the

inadequacy of OCC controller training, and

station/platform overruns on the Metrorail

system.

Elimination of Routine Manual Train

Operation

Prior to November 17, 1995, and apparently

for most of the 20-year history of the Metrorail

system, OCC controllers routinely gave

permission for train operators to change to

manual operation during periods of inclement

weather. This issue was important enough to be

addressed by rule 3.85 in the MSRPH, which

stated that revenue trains were to be operated in

manual mode during periods of inclement

weather or reduced visibility and as authorized

by the OCC.

The November 17, 1995, notice instructing

OCC controllers not to permit train operators to

change to manual mode ended this 20-year

policy. This notice, in combination with the

November 20, 1995, memorandum annulling

first-trip and once-weekly manual operation,

completely eliminated routine mainline manual

train operation on the Metrorail system.

This policy change was prompted by the

high number of wheel flats Metrorail trains

experienced between November 11 and 14,

1995. Some evidence suggested that most of

these wheel flats occurred when trains were

being operated in manual mode, but the exact

cause was unknown. On November 17, 1995,

WMATA engineers began planning tests to

determine the cause of the flats. Rather than

waiting for the results of those tests, however,

WMATA top management decided to deal with

the problem by curtailing manual train operation

across the entire Metrorail system. Even though

Metrorail officials stated that prior to this policy

change they had conducted some “limited” and

“undocumented” testing of all-ATC operation in

inclement weather and had experienced no

problems, no tests were done specifically to

determine how the system and the operators

might react if manual operation were eliminated

across the system. The Safety Board concludes

that the WMATA decision to completely and

suddenly replace its policy of intermittent

routine manual train operation with an

essentially untested policy of full-time

automatic train operation was a hasty decision

based on insufficient information.

Evidence also suggests that no one

monitored the effect of the new policy after it

was implemented. One possible effect was an

increase in station overruns. According to

reports prepared at the request of Safety Board

investigators, the Metrorail system, which had

recorded 14 overruns during the 17 days

immediately prior to the notice, experienced 9

station platform overruns on the first day after

the notice. In all, the system experienced more

than three times as many station overruns during

the last 14 days of November 1995 (after the

policy change) as during the first 16 days. The

upward trend continued in December, when the
50

system recorded 85 overruns. Factors other than

the policy change could have influenced these

overrun occurrences, but the sheer numbers of

events and their significant increase over the

same months in the previous 3 years clearly

should have invited further investigation. There

is no evidence, however, that Metrorail officials

noted these increases or considered their

implications.

Certainly, Metrorail officials would have

been expected to take particular note of wheel

flat occurrences after the November 17 policy

change, since reducing wheel flats was the

reason for the change. Apparently, this was not

done. According to a flat wheel summary

supplied by Metrorail, not only did the number

of wheel flats show no significant decrease after

November 17, the numbers actually increased.

During the 6 weeks prior to the policy change,

82 wheel flats were reported; during the 6 weeks

after the change, 92 were reported. While it is

true that the number of wheel flat incidents (as

opposed to the total numbers of wheel flats)

decreased in December, the month after the

policy change, the number decreased only in

relation to the exceptionally high number of

incidents in November. There were actually

more wheel flat incidents in December (50) than

in any other month of 1995 except February (51)

and November (164). The Safety Board

acknowledges that a combination of factors may

have contributed to these numbers, but the

numbers alone should have prompted Metrorail

officials to analyze the data to determine

whether eliminating manual operation was

having the desired effect. It is clear from the

available evidence that they made no such

analysis.

Two outcomes of eliminating manual train

operation were obvious and should have been

considered by WMATA management. The

reason WMATA initially scheduled one-dayper-week manual operation was “to allow train

operators to familiarize themselves with manual

train operation.” This was a worthwhile

objective, since, even in an environment of

“normal” automatic train operation, equipment

malfunctions, track maintenance, or other

conditions occasionally create the need for

manual operation. But the elimination of

scheduled manual operation left train operators

with no opportunity to develop or maintain

proficiency in operating trains manually in

revenue service. The Safety Board is concerned

that, without regular practice in manual train

operation, train operators will not be able to

develop and maintain self-confidence and attain

the level of proficiency needed to ensure safe

operations under non-ATC conditions. The

Safety Board concludes that WMATA, before

making the decision to eliminate manual train

operation on the Metrorail system, failed to

consider the continuing need for train operators

to maintain proficiency in manual train

operation. The Safety Board believes WMATA

should implement procedures that will provide a

means for train operators to develop and

maintain this proficiency.

The Metrorail policy of operating in manual

mode during the first trip each day was also

based on practical considerations. Officials

believed that train operators making the first trip

of the day in manual mode would be better able

to respond to unexpected or potentially

hazardous conditions that might have developed

overnight. This appears to have been a sensible

policy, yet it too fell victim to the decision by

WMATA management to curtail manual

operation systemwide.

In Safety Board interviews, WMATA

officials stated that automatic train operation is

“the safest operating mode we have.” This view

appears to have been widespread among

Metrorail top and middle management, and it

could be one reason why apparently no one in

the management chain seriously questioned—

much less objected to—the decision to curtail

manual operation across the system. Such was

the confidence in the automated system that

controllers were directed to defer to the ATC

system even when it displayed anomalies such

as allowing trains to exceed programmed

speeds. Even under those circumstances, human

controllers and train operators were told to stand

aside and allow the ATC system to “do what it

is supposed to do.” Thus, human operators and

controllers, who should at the very minimum
51

have been a backup to the automatic system,

were essentially removed from the process.

The Safety Board is fully aware of statistics

indicating that some 80 percent of all

transportation accidents are attributable to

human error. The Safety Board itself has been at

the forefront of efforts to promote the use of

automated systems in all transportation modes—

such as positive train separation systems in the

railroad industry—that will reduce absolute

reliance on operating personnel to ensure safe

operations. The Safety Board further

acknowledges evidence that, since the opening

of the Metrorail system, most accidents and

incidents have been caused by human operators

rather than by the automated operating system.

Nevertheless, the Safety Board believes that

total faith in technology, no matter how

advanced and sophisticated that technology may

be, is inappropriate and that technology should

instead be approached with a high degree of

informed caution.

WMATA top management did not display

that caution; instead it encouraged among

Metrorail employees a degree of confidence in

the ATC system that was wholly unjustified

given the system’s built-in limitations

(discussed elsewhere in this analysis). Had those

officials had less faith in the reliability and

inherent safety of the automatic train control

system, they may have considered their options

more carefully before mandating automatic train

operation in all weather conditions. Having done

so, they may have become aware of the

limitations of the system and may have put

procedures in place to accommodate them. In

effect, WMATA officials took such steps after

the accident when they issued Special Order 96-

2 requiring that, in inclement weather,

performance levels limiting train speeds to a

maximum of 49 mph be entered and confirmed

for all Metrorail route segments. If this special

order had been issued before the accident and if

it had been understood and followed, this

accident may not have occurred. The Safety

Board concludes that WMATA management

failed to fully understand the design features

and limitations of the ATC system, which led to

unjustified management confidence that the

system could ensure safe train operation under

all operating conditions.

Use of Performance Levels to Control

Train Speed

Under the November 1995 guidance,

degraded braking efficiency in bad weather was

to be accommodated solely by lowering

performance levels, which would reduce train

speeds and shorten braking distances. But the

use of performance levels to offset the effects of

inclement weather is far from foolproof. The

accident train operator overran the Twinbrook

station by all four cars, even though he entered

the station operating under a performance level

3, picked up at the White Flint station, that had

limited his top speed between White Flint and

Twinbrook to 44 mph. At Twinbrook, he picked

up the most restrictive level of 8, yet he still

overran the Rockville station platform by one

car.

More significantly, Safety Board tests

confirmed that when a train loses the assigned

performance level, it can default to the

highest—not to the safest—performance level.

While a train is servicing a station, it

temporarily loses the performance level

assigned to it. Once the doors are closed and the

train is ready to depart, the performance level is

reassigned—but only if the train is within the

platform limits. If the train has overrun the

station and the lead car is outside the station

track circuit, the train will default to the highest

performance level, with its top speed limited

only by the maximum ATP speed for the next

route segment. Even though WMATA officials

were aware of this default feature of the ATC

system, they nonetheless relied on performance

levels to control train speed, and they did not

establish a policy for dealing with trains that

experienced a default to the highest available

speed. By following established policy and

directing the operator of train T-111 to service

the Rockville station with one car off the

platform, the OCC radio controller inadvertently

set in motion the series of events leading up to

the accident.
52

Maximum Authorized Speed

The MSRPH states that train operators will

not operate rail vehicles at a speed higher than

the maximum authorized speed. An August 14,

1986, memorandum, subject “Adherence to

Regulated Speed,” made reference to 59 mph as

the maximum authorized speed and directed

train operators to notify the OCC should their

regulated (ATS) speed ever exceed 59 mph.

While this document was the only one that

Safety Board investigators were able to identify

that specifically referred to 59 mph as the

maximum authorized speed, many at Metrorail

regarded 59 mph as the maximum allowable

speed across the Metrorail system. On probably

no other question during this accident

investigation, however, did WMATA officials

and employees evidence more confusion and

provide more contradictory testimony.

The deputy general manager for operations

stated his belief that the 59 mph restriction was

still in force at the time of the accident and that

the OCC controller should have taken

immediate action to stop the accident train when

the operator reported receiving an ATS speed of

75 mph. He said, “When a train is running at 75,

even in dry weather, it indicates there is a

problem. So you must bring that train speed

back down to the maximum speed allowed,

which is 59, or find out what the problem is with

the train.”

But Metrorail officials produced no

evidence of any documentation or formal

instructions that would have told OCC

controllers that the general prohibition against

manual train operation should be waived if a

train received an ATS speed of 75 mph. In fact,

the general, though unwritten, guidance was just

the opposite, that trains should not be stopped

just because they received a regulated speed in

excess of 59 mph in automatic mode.

Testimony indicated that, to the extent that

59 mph was considered a maximum speed at all,

it was not thought to be a safety issue. The

deputy general manager for operations, who said

that the controller should have had the train

operator stop his train on the night of the

accident, stated that the 59 mph speed was

imposed to “save the wear and tear on the

equipment.” In other words, it was not intended

as a safety measure, which may explain why

exceeding 59 mph was not considered an

emergency. As shown by the accident, however,

maximum design speed could, under adverse

weather conditions, quickly become a safety

issue in light of the braking rate requirements

(discussed below) built into the ATC block

design.

The Safety Board concludes that WMATA

management, prior to the accident, did not have

a well-thought-out, firmly established maximum

authorized speed policy that was understood and

followed by all operating department

employees. Furthermore, WMATA management

failed to revisit the issue of maximum

authorized speed in the context of its decision to

curtail manual train operation on the Metrorail

system, which created confusion among those

employees, including OCC controllers and train

operators, who have primary responsibility for

ensuring system safety.

The Safety Board notes that after the

accident WMATA issued Special Order 96-2,

which specifies a maximum authorized speed of

49 mph during inclement weather. The special

order also explicitly spells out the actions that

should be taken by both train operators and

OCC personnel if a train receives an ATS speed

in excess of 49 mph. The Safety Board believes

that a similarly explicit special order or other

appropriate document should be published

regarding the maximum authorized speed that

applies in good weather. The Safety Board

believes that maximum authorized speeds

should be developed and published for each

Metrorail route segment and that these

published speeds should take into account the

physical layout, length, and other significant

features of each segment.

Railcar Braking Performance and Design

of the ATC System

Postaccident testing revealed no defect or

failure in train T-111’s braking system or its

slip/slide wheel protection feature. Safety Board

stopping distance tests conducted with a train
53

that was identical to train T-111 and that was

known to have no mechanical defects confirmed

that the accident train demonstrated the braking

performance that would have been expected

given the capability of the equipment, the speed

of the train, and the low-adhesion condition of

the rails. In most of the Safety Board tests, the

test train could not be decelerated from 75 mph

to a stop within the 2,822 feet that was available

for train T-111 to have made a proper stop at the

Shady Grove station platform. Three of the tests

resulted in stopping distances that were longer

than the 3,422 feet between the brake initiation

marker and the location of the gap train, and in

one test at 72 mph in automatic mode, the test

train did not come to a stop until it had traveled

335 feet past the point of impact.

According to WMATA documents, the

design specifications for the H-1 slip/slide

control unit called for a minimum braking

efficiency of 80 percent of the braking rate that

available track adhesion would support at all

adhesion levels above 5 percent. For Metrorail

cars, the available deceleration rate at 5 percent

adhesion is 1.1 mph/sec. To meet the

specifications, then, the slip/slide control unit

must be capable of achieving a minimum

deceleration rate of 0.88 mph/sec (80 percent of

1.1 mph/sec) at 5 percent adhesion.

WMATA acceptance test documents

confirmed that the slip/slide system in the series

2000 and 3000 cars met the specified 0.88

mph/sec deceleration rate; however, this rate is

incompatible with the design assumptions of the

Metrorail ATC system. According to

documentation provided by WMATA, the

Metrorail block design is safe, that is, the design

allows sufficient distance for a train to stop

without colliding with another train or some

other obstacle, so long as the effective brake

rate of the train is equal to or greater than 75

percent of the B2 full service brake rate of 2.2

mph/sec. Because the H-1 slip/slide control

units cannot always achieve this minimum

deceleration rate (1.65 mph/sec at 75 mph), they

cannot be expected always to guarantee safe

stops. In Safety Board tests conducted during

simulated low-adhesion conditions, the test train

did not achieve average deceleration rates as

high as 1.65 mph/sec at any test speed above 60

mph. The Safety Board therefore concludes that,

under extreme low-adhesion conditions, the

deceleration rates provided by the WABCO H-1

slip/slide control unit on Metrorail 3000-series

cars and specified in WMATA specifications

result in stopping distances that are longer than

can be safely accommodated by the ATC block

design.

This accident occurred at a terminal station,

but a similar accident could occur anywhere on

the Metrorail system where conditions make a

train deceleration rate of at least 1.65 mph/sec

unachievable. If a train, because of an

equipment malfunction or other reasons, were to

come to a stop on the mainline, the ATC system

would give any train following behind

appropriate speed commands (including zero

speed commands) to allow the train to stop in

time avoid a collision. But, as shown by this

accident, on outdoor track under extreme

weather conditions, the distance required to stop

the following train may be significantly longer

than the available track. During rush hour, with

crowded trains, scores of people could be killed

or seriously injured.

WMATA officials told Safety Board

investigators that they became aware of the

incompatibility between the ATC block design

and train braking capability only after the

accident when they compared the braking

profile of the accident train with the profiles

generated during their own slip/slide system

tests conducted in November and December

1995. But from the beginning of Metrorail

operations, the documented specifications for

the slip/slide system called for and allowed a

minimum braking capability that was clearly

“outside the envelope” of the safety

requirements of the ATC block design.

This incompatibility between the braking

requirements of the ATC block design on the

one hand and the braking capability of certain

Metrorail cars in low-adhesion conditions on the

other likely existed for most, if not all, of the

20-year history of the Metrorail system. But the

problem was masked by WMATA’s policy of
54

operating trains manually in inclement weather,

a policy that made stopping accuracy a function

of the judgment and experience of the train

operator rather than a function of the block

design. When WMATA severely restricted

manual train operation in November 1995, the

incompatibility between train stopping

capability and ATC block design became a

serious safety issue. Unfortunately, a fatal

accident occurred before the problem was

brought to light and procedures were developed

to address it. The Safety Board believes that

WMATA should analyze the braking

performance of all railcar series in the Metrorail

fleet and take the measures necessary to ensure

compatibility between that braking performance

and the ATC block design.

The ATP subsystem is a vital subsystem of

fail-safe design. A train will not operate at a

speed greater than the ATP speed. As noted

above, however, in adverse weather, ATP

speeds can result in train stopping distances that

exceed the safety margin built into the ATC

block design. WMATA management recognized

that some speed adjustments may be necessary

during periods of inclement weather, even when

operating in automatic mode, and they relied

upon the automatic train supervision subsystem

to provide those speed reductions. Thus, a nonvital and non-fail-safe subsystem was called

upon to provide a safety-critical function. Had it

been fail-safe in design, the ATS subsystem

would have defaulted to the safest state when

train T-111 failed to receive an ATS speed

transmission before leaving the Rockville

station, and the accident probably would not

have occurred.

The Safety Board therefore concludes that

WMATA at the time of the accident was using

the non-safety-critical ATS subsystem to

perform safety-critical functions. The Safety

Board is concerned that although WMATA

depends heavily on the ATS subsystem to

provide safe operation of trains, that system

does not comply with basic fail-safe design

requirements because when a failure occurs, the

system does not always revert to its safest state.

The Safety Board believes that WMATA should

discontinue the use of the non-vital and non-failsafe ATS subsystem to perform safety-critical

functions, and make it impossible for trains to

default to the current “design” or “limiting”

speeds under any circumstances. This may

require converting the existing ATS system into

a vital system or rewiring ATP circuits to reflect

maximum authorized speeds rather than design

speeds. If such engineering changes are not

technically or economically feasible, then welldocumented procedures should be developed

that would prevent a repeat of the events that

occurred on the night of the accident.

Adherence to Operating Rule-Change

Procedures

The November 1995 change in the

longstanding operating policy of allowing train

operators to switch from automatic to manual

mode during inclement weather represented a

change to rule 3.85 of the MSRPH:

During inclement weather or

when visibility is limited, Class

I vehicles shall be operated in

Mode 2 level 1 in compliance

with Special Order 94-

02/Operating Rule 3.21 and

shall enter stations at a speed no

greater than 25 mph.

The MSRPH outlines three methods that can

be used to change an existing rule. The Safety

Board reviewed these procedures and believes

that they incorporate effective checks and

balances to ensure that the MSRPH is properly

maintained and updated. As revealed during this

investigation, however, WMATA did not follow

the rule-change procedures established by the

MSRPH when it used a “notice to OCC

controllers” to change rule 3.85. To have been

in compliance with the MSRPH, this notice

should have been issued as a special order or

other document appropriate to effect a change in

operating rules. The rule change had obvious

safety implications, since it put a burden on the

ATC system that it had not been designed to

assume. Consequently, the WMATA Office of

Safety should have been consulted before the

change was made, but it was not. The Safety

Board concludes that the November 17, 1995,

notice instructing OCC controllers that they
55

were not to permit train operators to change

from automatic to manual mode constituted a

change to MSRPH rule 3.85 and that in issuing

the notice, WMATA management failed to

comply with its own established formal

procedures for making changes to operating

rules.

Because existing rule-change procedures

were circumvented, the normal checks and

balances that should have been in place were

absent. Thus, the policy change did not receive

the scrutiny from various operational

perspectives that may have helped ensure that

the decision was well thought out and that all its

ramifications were considered. Had all relevant

Metrorail operating elements been brought into

the decisionmaking and rule-change process, the

potential problems with relying on the non-vital

ATS subsystem to provide speed control and to

ensure safety could have been raised and

addressed. The Safety Board believes that

WMATA should establish management controls

to ensure that changes to Metrorail operating

policy are properly evaluated before adoption

and that any such changes that may constitute a

change in operating rules are made in

compliance with formal rule-change procedures

and are fully coordinated with all appropriate

WMATA branches and divisions.

Gap Train Placement

WMATA management recognized that

positioning a gap train on the same track as

incoming trains presented an unnecessary risk

and had given “verbal” instructions that gap

trains were to be placed on the track opposite

that of arriving trains. As shown by the January

6 collision, which would not have occurred if

the gap train had been located on the adjacent

track, these oral instructions were totally

inadequate. To the extent that the instructions

were known at all to those who were to be

governed by them, they were frequently

violated. WMATA management apparently

failed not only to properly promulgate the

policy, but to enforce it. The terminal supervisor

on duty the night of the accident stated that

other supervisors had mentioned the policy, but

that those same supervisors regularly violated it.

That the gap train at Shady Grove was often left

on track 2 was widely known; for example, both

Red Line controllers on duty at the time of the

accident were aware of it, and at least one of

them knew from previous experience that the

train was not supposed to be there. He did not,

however, make any effort to have the train

moved. This illustrates the apparent indifference

with which WMATA management and

employees regarded the policy of gap train

placement.

Only after the accident, on February 14,

1996, did WMATA management formalize its

gap train placement policy systemwide by

ordering, in writing, that gap trains be stored on

the track opposite the one normally used for

trains arriving from the mainline and that they

be positioned as deep as possible in the tail

track. The Safety Board concludes that if

WMATA management had initially issued

written, rather than oral, instructions regarding

the safe placement of gap trains and had ensured

that this policy was known and followed, the

gap train at Shady Grove would probably not

have been located where it was on the night of

the accident, and the collision would not have

occurred.

The Safety Board believes that, because of

its safety-critical nature, the February 14, 1996,

policy should be formalized and promulgated as

an operating rule. Such a rule, if enforced, will

directly enhance Metrorail safety by reducing

the risk of a collision of the kind experienced in

this accident. The Safety Board believes that

WMATA should take the measures necessary to

inform employees of the new rule and to enforce

adherence to it.

Metrorail Reliance on Oral Instructions

As a result of its investigation of a January

1982 Metrorail fatal accident, the Safety Board

issued Safety Recommendation R-82-63, which

asked that WMATA cease using oral

instructions to OCC controllers that modified or

amended operating rules and standard operating

procedures. WMATA responded that it had told

OCC personnel that they would not be given

oral instructions that modified operating rules or
56

standard operating procedures but would instead

be governed by the book of rules until the rules

were changed by a written revision of the rule

book or by special order. On the basis of this

response, the Safety Board classified this

recommendation “Closed--Acceptable Action.”

Evidence gathered from this accident

investigation indicates that the procedures

spelled out in WMATA’s response to Safety

Recommendation R-82-63 are no longer being

followed. As noted above, WMATA

management in November 1995 changed the

rule regarding manual train operation in

inclement weather with a notice to OCC

personnel. This notice did not meet the

definition either of a written revision of the rule

book or a special order. Furthermore, as is clear

from this accident, Metrorail is still relying on

oral instructions, if not within the OCC, then

certainly among other Metrorail employees and

supervisors.

For example, the instructions regarding

placement of the gap train at the Shady Grove

yard were oral instructions. Because they were

not written down and properly disseminated,

these instructions did not reach everyone who

had responsibility for carrying them out; to the

extent that they did reach employees, they were

not given a great deal of weight. Even the

important November 17, 1995, notice

prohibiting routine manual train operation began

as an oral instruction from the general

superintendent for rail transportation, who

stated that he did not recall asking the OCC

supervisor to put the new guidance in writing.

Metrorail management apparently considered

oral instructions to be perfectly adequate, even

when those instructions involved a policy

change that actually constituted a change to an

operating rule.

The Safety Board concludes that WMATA

management relies too heavily on oral

instructions to convey operations and safety

information to its managers, supervisors, and

employees. The Safety Board believes that

WMATA should develop clear guidelines and

formats for the written dissemination of

information and should completely eliminate the

practice of conveying important information

orally.

An over-reliance on oral instructions was

not the only deficiency the Safety Board noted

in Metrorail procedures for disseminating

information. WMATA managers told Safety

Board investigators that Metrorail had no formal

procedures to ensure that train operators,

terminal supervisors, OCC supervisors and

controllers, or other operating personnel actually

received memoranda or notices meant for them.

The Safety Board is concerned that the

Metrorail practice of posting memoranda or

notices on bulletin boards or placing them in

mailboxes gives no assurance that employees

will actually receive the information, and it

leaves no documentary record that employees

have read and understood important safetyrelated guidance.

By requiring employees to sign for safetysensitive written bulletins, special orders,

memoranda, or notices, WMATA could be

assured that employees have received those

documents. The Safety Board therefore believes

that WMATA should develop and implement

procedures to ensure that Metrorail operations

personnel receive all bulletins, special orders,

memoranda, or notices related to their

responsibilities. These procedures should

include a mechanism by which these personnel

must sign or initial a document to signify that

they have received, read, and understood any

guidance intended for them.

WMATA Management, Decisionmaking,

and Communication

As noted above, this investigation

determined that when WMATA top

management made the decision to require

exclusive automatic train operation, it

overlooked or failed to consider all the

ramifications of the decision. It was further

determined that while the OCC responded

effectively to train scheduling problems and

otherwise followed basic system operating

instructions, OCC personnel relied heavily on

system automation to ensure safe train

operation. The investigation also determined
57

that important information was often not

communicated effectively between and among

operating departments and employees and that

several key operating rules were not enforced or

even understood by management or operating

personnel. Thus, the Safety Board concludes

that WMATA management and its board of

directors, at the time of this accident, was not

providing adequate direction to ensure safety on

the Metrorail system.

The investigation revealed that many, if not

most, important Metrorail policies and operating

procedures were derived from rigid, top-down,

highly centralized management processes.

Apparently, many important decisions emanated

from the deputy general manager for operations

and were dutifully, and generally without

question, carried out by senior and middle-level

managers. This was apparently the case with the

decision to require exclusive automatic train

operation. Metrorail engineering personnel had

access to information regarding the

incompatibility between the ATC block design

and the stopping profile of trains in inclement

weather, but this information was not sought out

or considered during the decisionmaking

process. In fact, before the accident, the decision

to require exclusive automatic train operation

was known only to senior management and

OCC personnel. That decision, with its defects,

thus went into effect without the knowledge of

train operators or key individuals in the safety,

training, or engineering departments who could

have pointed out its shortcomings. The

inflexibility of this highly centralized structure

also explains the adherence of OCC controllers

to the exclusive automatic train operation

decision after train overruns began occurring on

the night of the accident.

The Safety Board found WMATA

management policies and methods to be

inconsistent with the needs of a technically

complex automated rail system. Systematic

analyses of organizational processes reveal that

managers operating highly automated systems

must successfully contend with unique demands

presented by the automation itself. One

fundamental requirement for managing

automated systems is to contend effectively with

“tight coupling” between different operating

elements in the system.33 That is, in

organizations operating highly technical

automated systems, decisions that affect one

activity in the organization will probably affect

other activities and will sometimes produce

unanticipated hazards.

High-technology organizations must also be

capable of both centralized and decentralized

control.34 Operating activities need to be

controlled within “tightly prescribed steps and

invariant sequences,” thereby ensuring that

actions suitable in one circumstance or

departmental area do not conflict with other

activities in the system. At the same time,

operating personnel occasionally have to be able

to take “independent and sometimes...creative

actions” in order to prevent the development of

unsafe conditions.35 Finally, high-technology

organizations must have safeguards to prevent

unsafe conditions that may result when the

automation compensates temporarily for

deficient operation and then fails to protect the

system when unforeseen factors combine and

breach the system’s safeguards. This condition

poses the greatest threat to the safety of a

complex system and must be addressed in wellconceived system planning.36

Given the extent to which WMATA

executive management was found to depart from

these essential organizational characteristics, it

is not surprising that flawed decisions,

inadequate or ambiguous train control

procedures, and poorly understood or

unenforced rules had proliferated. The Safety

Board believes that effective management of a

high-technology system such as Metrorail

requires skilled and informed decisionmaking,

 33 Reason, J., Human Error, Cambridge University

Press, New York, 1990, pp. 177-178.

34Perrow, C., Normal Accidents: Living with HighRisk Technologies, Basic Books, New York, 1984, p. 10.

35Ibid.

36Ibid., p. 173, and Maurino, D. E., Reason, J.,

Johnston, N., and Lee, R. B., Beyond Aviation Human

Factors: Safety in High Technology Systems, Ashgate

Publishing Co., Brookfield, Vt., 1995, pp. 7, 10-13.
58

unambiguous operating procedures that can be

expected realistically to safeguard the system

from all hazardous contingencies, and timely,

open access to information for all operating

personnel. WMATA executive management

apparently did not comprehend that these

organizational processes are essential for

managing the technology of the system, and they

therefore failed to provide adequate policies and

procedures to ensure safe train operation.

OCC Controller Training

The Safety Board determined that WMATA

did not have a recurrent formal training program

for OCC controllers. While controllers were

required to pass an annual rules test, they were

not provided with any review or other

preparation for taking the test. Additionally,

WMATA had no program to ensure that

controllers remained familiar with the physical

characteristics of the route segments over which

they had responsibility. The Safety Board is

concerned that without recurrent training on

operating rules, safety instructions, policies, and

diagnostic procedures, physical characteristics

of the Metrorail system, and emergency

notification procedures, OCC controllers are not

properly prepared to carry out their safetycritical function. The Safety Board concludes

that, as demonstrated by this accident, the

training given to OCC controllers by WMATA

before the accident was inadequate to prepare

them to safely manage and control the highly

automated Metrorail system. The Safety Board

notes that after this accident, WMATA

established a training program for OCC

controllers. The Safety Board believes that this

training effort should form the basis for a

comprehensive, recurrent training and

qualification program for OCC controllers that

includes, at a minimum, instruction and testing

on WMATA rules, policies, and procedures;

emergency preparedness and notification;

Metrorail signal and control systems; and the

physical characteristics of the Metrorail system.

This program should be formalized as a

permanent element of OCC operations and

should be monitored and updated on an ongoing

basis to ensure that it continues to meet the

requirements of the evolving Metrorail system.

Performance of Controllers and Train

Operator

The OCC Environment -- Two highly

experienced controllers were assigned to the

Red Line at the time of the accident, and their

activities were directly supervised by the OCC

superintendent. The controllers and the OCC

superintendent were familiar with train

operations in inclement weather. There was no

evidence of poor communication among the

controllers and the OCC superintendent, and the

controllers had been working together for

several months and were familiar with each

other’s work patterns.

The Safety Board considered the possible

effects on OCC performance of the increased

workload demands and the distractions caused

by the developing snow storm. The OCC was

responsible for obtaining shelter for overnight

storage for trains in addition to providing rail

system operating control. At the same time, train

operators were reporting overruns, and the

controllers were adjusting performance levels at

various locations. Nonetheless, the nature and

pace of recorded communications indicate that

neither the controllers nor the OCC

superintendent were unduly distracted by the

increased workload, nor did they seem to be

preoccupied with any single ongoing problem

between the time they began their shift and the

time the accident occurred.

The Safety Board is concerned that OCC

personnel did not see the accident developing as

soon as train T-111 was directed to service the

Rockville station. The Red Line radio controller

knew that when trains overrun station platforms

and then service those stations, they often lose

the correct performance level and default to the

highest available speed as they leave the overrun

station. Yet, transcriptions from OCC overhead

microphones indicate that even when the

controllers were made aware that train T-111

had received an ATS speed of 75 mph, they had

no conversations between themselves or with
59

their superiors to the effect that allowing the

train to continue operating in automatic mode

could have serious consequences. This lack of

expressed concern is particularly troublesome in

that the following information was known or

knowable to the Red Line controllers and the

OCC superintendent:

• Train T-111, as well as other trains,

had overrun stations even while

operating under reduced performance

levels, indicating that the stopping

capabilities of the trains were

unpredictable;

• A severe snow storm was moving

into the area, and track conditions

were worsening rapidly;

• Train T-111 was reporting a speed

that was significantly higher than

normal and higher than the speed the

train was traveling before it overran

the previous two passenger stations;

and

• The track on which train T-111 was

operating into the Shady Grove

station was occupied by another train

approximately 1 1/2 train lengths

past the station.

According to testimony by controllers and

the OCC supervisor, WMATA management had

made it clear that a train’s receipt of an ATS

speed of 75 did not, in and of itself, qualify as

an emergency. As noted above, however, this

emergency was not created by the excess speed

but by a confluence of circumstances, of which

excessive speed was only one, albeit an

important one. Had OCC personnel been trained

to anticipate all reasonable contingencies and

authorized to actively control Metrorail

operations rather than simply to respond to

events and follow instructions, they would have

recognized immediately that train T-111 was

facing a hazardous situation that demanded

prompt action. They may not then have relied on

general operating policies, or even on their

supervisors, to tell them what to do, but instead

may have taken the decisive action necessary to

break a link in the chain of events that led to the

accident. The most obvious action would have

been to stop the train. If the OCC had instructed

the operator of train T-111 to bring his train to a

stop and change to manual operation as soon as

the operator reported regulated and limiting

speeds of 75 mph, the accident may not have

occurred.

Testimony indicated that Red Line

controllers had, in the half hour preceding the

accident, asked for and been denied permission

to permit train operators to change to manual

mode. These requests came after trains had

reported overrunning stations because of

slippery rails. But the controllers did not make

this request specifically with respect to train T111, even though that train presented them with

a safety hazard that was far more serious and

more immediate than any they had faced since

their shift began. The controllers apparently

were not able to diagnose the problem as one

that required more than adherence to standard

operating procedures. Perhaps more

disturbingly, evidence suggests that if they had,

in fact, diagnosed the full extent of the problem,

they would have been prevented from taking the

proper action because no authorized procedures

had been developed, and the rigid management

controls within the OCC and WMATA required

certain decisions to be approved by executive

management. The Safety Board therefore

concludes that OCC controllers, and, to a

degree, their immediate supervisors, had

responsibility for day-to-day train operations,

but they lacked the authority and the systematic

procedures necessary to effectively carry out

that responsibility.

In the view of the Safety Board, such

conditions are not consistent with the

requirements of an effective central control

operation. These requirements include the

ability to diagnose conditions and anticipate

contingencies that present operating hazards and

the authority of controllers to take remedial

actions according to established procedures. The

Safety Board concludes that the deficient

performance of the OCC on the night of the

accident resulted from top-level WMATA

management policies and decisions in that

Metrorail management did not create an
60

environment in which OCC controllers were

encouraged to use their own experience,

knowledge, and judgment to make decisions

involving the safety of Metrorail operations.

The Safety Board believes that WMATA should

develop and implement procedures for OCC

controllers that provide for active monitoring of

both the automated control system and of

revenue train operation, that permit standardized

interventions at the onset of recognition of

potential automated system failures as well as

direct hazards to individual trains, and that

include unambiguous, clear guidelines for

recognizing emergency operating situations

requiring the stopping of trains.

Train Operator’s Actions During the Accident

Sequence -- Under rule 3.1 of the MSRPH, the

train operator clearly had the authority, if not

the obligation, to stop his train if he perceived

the train and its passengers to be in danger,

regardless of the instructions from the OCC. It is

not at all clear, however, that the operator fully

recognized the extent of the hazard. He had been

a train operator for only a little more than 2

months and, because of speed restrictions

normally in place throughout the system, he

probably had never before operated a train at a

speed greater than about 60 mph. He almost

certainly had never operated a train in weather

conditions such as those experienced on the

night of the accident, and he thus would have

been unaware of the braking capabilities of his

train under those conditions.

In accordance with his training, the train

operator immediately reported his abnormally

high ATS speed readout, and the controller did

not suggest to the train operator that his

situation was in any way perilous, instructing

him instead to remain in automatic mode. This

may have given the train operator a false sense

of security and led him to believe that no action

on his part was required. The train operator had

no way of knowing that OCC controllers were

operating under strict orders not to authorize a

change to manual mode, because the November

17 notice conveying these orders went only to

OCC personnel, not to train operators. The

November 20 memorandum addressing

automatic versus manual operation did go to

train operators, but that memorandum merely

restated the existing operating rule, which was

that no train operator could change to manual

mode without OCC permission. The November

20 memorandum was blatantly misleading

because it implied that no alteration had been

made in the policy regarding changing from

automatic to manual mode when, in fact,

because of the November 17 notice, requests for

such a change would almost always (except for

undefined “emergency situations”) be denied.

Had the train operator wanted simply to

slow his train without changing into manual

mode, he would not have been able to do so; his

only two options to reduce his speed were to

initiate an ATO stop or an emergency stop—

either of which would have been in direct

violation of OCC instructions. Again, because

of his limited experience as a train operator, he

may have been reluctant to violate OCC

instructions, even if he did have some

uncertainty about the safety of his train.

The Safety Board examined the question of

whether the train operator at any point used the

mushroom button to attempt an emergency stop.

Although the button was found in the depressed

position, it could have been pushed down as a

result of the collision. No wheel flats were

found on the train, and no significant marks

were present on the rails or on the wheels that

would have provided conclusive evidence that

the train had slid along the rails with the wheels

locked. This would seem to indicate either that

that mushroom button was not depressed by the

operator before impact, or that it was depressed

too late to have had any effect.

Track conditions on the night of the

accident, however, were unusual. The rails were

cold and possibly ice-covered; the deceleration

rate exhibited by the accident train indicated

that available rail adhesion was extremely low.

Even if the train operator had used the

mushroom button at some point before passing

through the Shady Grove station, the amount of

friction between the cold wheels and the cold

and icy rails may have been insufficient either to

slow the train appreciably or to generate the heat

necessary to produce skid marks. The Safety
61

Board therefore concludes that the evidence is

insufficient to indicate whether the train

operator activated the emergency stop button

before impact, but if he did activate emergency

braking, he did so too late to avoid the collision.

The Safety Board further concludes that the

accident train operator acted in accordance with

his limited experience when he followed OCC

instructions and did not undertake unilateral and

exceptional action to stop his train.

Train Operator’s Use of Prescription

Medications -- A prescription vial containing

Tylenol 3 was found among the train operator’s

belongings. Postaccident toxicological tests of

the operator revealed the presence of codeine

(and its metabolite), an analgesic and ingredient

in Tylenol 3, in sufficient quantity to indicate a

therapeutic use of the medication. The tests also

detected four ingredients commonly found

combined in over-the-counter cold medications.

Because the train operator’s actions from

the time he overran the Twinbrook station until

the time of the accident were timely and

appropriate and did not indicate any sign of

impairment, the Safety Board concludes that he

probably did not suffer any of the possible side

effects associated with the use of Tylenol 3. He

apparently had used the medication for several

months and had knowledge of how it affected

his performance. Nonetheless, the Physicians’

Desk Reference37 advises that patients using the

medication be given the warning that “codeine

may impair the mental and/or physical abilities

required for the performance of potentially

hazardous tasks such as driving a car or

operating machinery.”

The Safety Board cautions against persons

in safety-critical jobs taking a medication with

codeine and is concerned that the WMATA

medical office permitted the train operator to

use Tylenol 3 while on duty, albeit in

substantially reduced dosages. The Safety Board

believes that when transportation employees

take such medications, even in moderate

 37Physicians Desk Reference. Montvale, NJ: Medical

Economics Company, 1996, p. 1583.

dosages to control discomfort, they should not

be permitted to perform safety-critical tasks

unless there is clear evidence that the

medication will not adversely affect their

performance. The train operator’s medical

records contained no documentation of this

precaution, nor did they contain a warning of

possible side effects or possible interactions

with other medications.

The medical office advice to the train

operator to use Tylenol 3 cautiously at the time

he was working as a station manager suggests

that WMATA appreciates the potential hazards

associated with use by employees of this

commonly prescribed pain medication, which

contains codeine, while they are at work.

However, the fact that there was no evidence

that the medical office followed up on its advice

after the train operator transferred to rail service

suggests that more needs to be done. In fact, this

investigation revealed that WMATA did not

have an education program for employees in

safety-critical positions that dealt with the use

and effects of medications. The Safety Board

believes that WMATA should establish and

administer a comprehensive educational

program to alert employees to the potential

adverse effects on performance that may arise

from the use of prescribed and over-the-counter

medications. The program should stress the

importance of seeking informed medical

approval for use of all medications and remedies

and should document the responses to

medications of employees who work in safetycritical positions.

As a result of its investigation of a 1991

National Railroad Passenger Corporation

(Amtrak) derailment in Palatka, Florida,38 the

Safety Board made the following safety

recommendation to Amtrak:

R-93-17

Develop and implement an

educational program for

employees that describes and

 38Railroad Accident/Incident Summary Report--

Derailment of Amtrak Train 87, Silver Meteor, in Palatka,

Florida, on December 17, 1991 (RAR-93/02/SUM).
62

illustrates potential consequences of medication use to

enable employees to make an

informed decision about the

relationship between their use

of prescribed and over-thecounter medications and their

fitness for duty.

In a March 16, 1995, letter, Amtrak stated

that it had completed and deployed, as part of its

annual rules training program for locomotive

engineers, a discussion on the use of

prescription and over-the-counter medications.

Amtrak also stated that it had developed an

information guide (appendix I) that was

distributed to all locomotive engineers and that

formed the basis for a group discussion. Based

on this response, the Safety Board classified

Safety Recommendation R-93-17 “Closed--

Acceptable Alternate Action” on May 25, 1995.

The information developed by Amtrak in

response to this recommendation may be useful

to guide WMATA’s development of printed

materials in support of its education program.

Event Recorders

No highly automated rapid transit system in

the United States equips its trains with devices

that monitor and record all vital train systems

and system events; this despite the fact that the

data provided by such devices could help those

agencies enhance the efficiency and costeffectiveness of their operations by providing

engineering, signal, maintenance, operations,

and training departments with vital information

about the way their systems and their operators

are performing. Such data can also be invaluable

in the event of an accident. Because train T-111

was not equipped with an event

monitor/recorder, Safety Board investigators

had to gather, interpret, and interpolate

information from a number of sources before

they could reconstruct the accident sequence

and evaluate the electronic, mechanical, and

human performance factors that led to the

collision. Although the lack of an event recorder

did not affect the outcome of this investigation,

the Safety Board believes that the absence of

event monitors/recorders on rapid transit trains

represents a potentially serious obstacle to

investigators attempting to determine the cause

of accidents on rail systems responsible for

moving millions of passengers daily.

The Safety Board acknowledges WMATA’s

efforts to foster development of advancedtechnology carborne monitors and to facilitate

their eventual installation on Metrorail cars. The

Safety Board is concerned, however, that this

process has been underway for 14 years and that

Metrorail trains still are not equipped with

carborne recorders/monitors that capture even a

minimal amount of information. Had Metrorail

cars been so equipped, WMATA management

may have been able to precisely pinpoint the

cause of the increase in wheel flats that led to

the November 1995 policy change, and perhaps

that change would not have been made. In view

of this, the Safety Board believes that WMATA

should finalize the specifications for a new

advanced-technology carborne monitoring

system and, once that is complete, retrofit

existing Metrorail cars with the

monitors/recorders during rehabilitation and

require that all new Metrorail cars be equipped

with the devices.

The Safety Board further believes that the

Federal Transit Administration, with the

assistance of APTA, should develop guidelines

for monitoring/recording devices that capture

critical performance and event data for rapid rail

transit cars and urge transit agencies to install

these devices on new and rehabilitated cars.

Emergency Response

Three Metrorail employees who were on

duty at the Shady Grove passenger station at the

time of the collision were the first to reach the

accident scene; two of them arrived within 1 to

2 minutes of the collision. Volunteer and fulltime firefighters of the Montgomery County

Department of Fire and Rescue Services were

notified by WMATA of the accident

approximately 4 minutes after the collision and

were on the scene within 9 minutes of the

accident.

The statement by the physician passenger

that no one made any attempt to communicate
63

with him or his fellow passenger immediately

after the accident conflicts with the statements

of two of the Metrorail employees who were the

first to arrive on the scene. If the statements of

the two Metrorail employees are accurate, then

the physician and his fellow passenger had two

conversations with Metrorail personnel before

the physician passenger became concerned and

attempted to attract the attention of rescue

personnel by pounding on the train window. The

testimony of the gap train operator was

corroborated by the yard tower radio tapes,

which confirm that within 9 minutes of the

collision he had become aware of the presence

of the two uninjured passengers. The inability of

the physician passenger to remember his

conversations with Metrorail personnel can

possibly be explained by the fact that those

conversations took place within minutes of the

passenger’s having experienced a traumatic

event that included his being thrown into the

bulkhead.

Passenger evacuation and firefighters’

efforts to search the lead car of train T-111 for

passengers were delayed because the third rail

was not deenergized immediately after the

accident. The fact that a portion of the energized

third rail lay in the interlocking posed special

problems for firefighters because they had no

schematic diagrams of the third-rail circuit.

Sections of third rail that lie within interlockings

have gaps that make it difficult to determine

visually how the sections of third rail are

interconnected. In this case, firefighters had

difficulty judging how many WSADs were

needed and how they should be placed. The

Safety Board concludes that third-rail

schematics would have aided firefighters in the

placement of their WSADs and would have

helped ensure safe movement of rescue

personnel throughout the accident area. The

Safety Board therefore believes that WMATA

should develop a mechanism to provide

emergency rescue personnel responding to an

accident anywhere on the Metrorail system with

easily accessible information about third-rail

circuitry. Such a mechanism could include or

consist of posting schematics or third-rail circuit

diagrams on all blue light boxes and fences

adjacent to interlockings.

When Montgomery County rescue

personnel arrived on the scene, they were

equipped with only one WSAD. Although two

more WSADs arrived sometime later, because

this accident occurred near an interlocking, a

minimum of four WSADs would have been

required, one on each independently controlled

section of third rail, to ensure that rescue

personnel would have been warned of third-rail

reenergization in the accident area. The Safety

Board therefore concludes that the number of

WSADs that was delivered to the accident site

was insufficient to fully protect emergency

rescue personnel working in the vicinity of the

interlocking. Because of the large number of

interlockings throughout the Metrorail system,

the Safety Board believes that all emergency

response stations with primary responsibility for

responding to Metrorail accidents should be

equipped with an adequate number of WSADs

or similar devices to monitor third-rail power in

an accident location that encompasses one or

more interlockings. The Safety Board believes

that WMATA should work with these agencies

to procure an adequate number of these

protective devices and ensure that they are

properly distributed among emergency rescue

stations that may be called upon to respond to a

Metrorail accident.

Firefighters and their commanders at the

scene did not attempt to establish a direct

communications link with the OCC to determine

the status of the third rail, even though their own

standard operating procedure states that this is

to be done. Instead, firefighters communicated

with Metrorail personnel at the scene, who

relayed these communications to the yard tower

or to the OCC by radio. This created confusion;

for example, Metrorail personnel at the scene

called the tower on several occasions and asked

that the third rail in the accident area be

deenergized. They were apparently not aware

that third-rail power in the area where the

accident occurred is controlled by the OCC and

not by the yard tower.
64

The Safety Board concludes that the failure

of the rescue commander at the accident scene

to immediately establish a direct command link

with the OCC caused miscommunications and

delays in deenergizing the third rail that

unnecessarily put firefighters at risk. The Safety

Board believes that WMATA and the

emergency rescue services of all the

jurisdictions served by Metrorail should

undertake more frequent joint command and

control exercises with the explicit goal of

ensuring that a proper command and

communication structure is established quickly

between the OCC and responsible rescue

commanders. The Safety Board further believes

that the Montgomery County Fire and Rescue

Commission should review its standard

operating procedures and revise the procedures

or the training program as necessary to address

the failure of rescue commanders on the scene

of this accident to establish an immediate and

direct communications link with the Metrorail

OCC.

Immediately after the accident, the OCC

Red Line button controller attempted repeatedly

to deenergize that section of third rail in the

accident area that could be controlled remotely

from the OCC. These attempts failed when

circuit breaker 33 did not respond to trip

commands from the Red Line command

console. Safety Board investigators were unable

to test the nonresponsive breaker because

WMATA officials provided incorrect

information about its postaccident disposition.

Although WMATA personnel have reported no

problems remotely tripping the circuit breaker

that since the accident has been designated

breaker 33, they have been unable to determine

why the circuit breaker at that location on the

night of the accident could not be tripped from

the Red Line console. This was not a unique

incident; WMATA engineers told Safety Board

investigators that various circuit breakers have

failed to respond to remote trip commands

before and that the source of the problem has

never been identified. Because this could have a

direct bearing on passenger safety, the Safety

Board believes that WMATA should frequently

test all Metrorail third-rail circuit breakers and

that such tests should include the capability of

OCC personnel to trip the circuit breakers

remotely. The source of any failures should be

identified and corrected.

As soon as it became obvious that the circuit

breaker could not be tripped from the OCC, an

OCC controller or other OCC official could

have directed Metrorail or rescue personnel at

the accident scene to bring down third-rail

power locally by using a nearby emergency trip

switch. Instead, WMATA management decided

to leave this section of third rail energized in

order to accommodate trains en route into the

Shady Grove station. Safety Recommendation

R-82-17, made by the Safety Board to WMATA

after a fatal Metrorail accident in 1982, asked

WMATA to amend its OCC operating

procedures to “require that, whenever a train

emergency which requires evacuation is known

to exist at a location between stations, all thirdrail power circuits between the emergency

location and the stations on each side of that

location be deenergized as soon as all other

trains have cleared the area.” Based on

WMATA’s response that procedures were

established to remove third-rail power from an

affected area before passengers were permitted

on the track bed, this recommendation was

classified “Closed--Acceptable Action.” It

appears that the procedures established by

WMATA in response to this safety

recommendation were either inadequate or were

simply not followed after this accident.

A WMATA official defended the decision

to leave the third rail energized by saying that it

was WMATA policy not to strand trains

between stations. However, when the accident

occurred, there were no trains receiving power

from this section of third rail, and the next train

into Shady Grove, train T-112, did not leave the

Rockville station until 10:45:35, which was

some 7 minutes after the accident occurred, 5

minutes after the OCC was notified of the

accident, and 2 minutes after the OCC controller

had tried unsuccessfully to trip the circuit

breakers. The appropriate response by OCC

personnel would have been to hold train T-112

at Rockville until the full extent of the accident

could be known. Even after the OCC became
65

aware that passengers, an injured train operator,

and firefighters were at the accident scene, the

OCC controller permitted two more trains to

proceed into the Shady Grove station.

The decision to leave the third rail energized

delayed passenger egress from the train and the

search of the lead car of train T-111. The Safety

Board therefore concludes that WMATA acted

improperly when it did not halt train traffic into

Shady Grove and turn off third-rail power in the

accident area immediately after the OCC was

notified of the collision. The Safety Board

believes that WMATA should amend its

standard operating procedures to require that

OCC personnel divert all train traffic from an

accident location as soon as possible after the

accident and deenergize the third-rail circuits in

the area of the emergency, including those on

adjacent tracks, as soon as trains have left the

vicinity.

Crashworthiness of Metrorail Cars

Even though both train T-111 and the gap

train consisted of Breda 3000-series railcars, car

3252, the lead car of train T-111, sustained

damage that was vastly disproportionate to that

sustained by the lead car of the gap train.

When car 3252 struck the gap train, the

attachments and fasteners securing its end

underframe assembly to the side sills failed, and

the side sills moved outward. On car 3191 (the

lead car of the gap train), the end underframe

assembly remained attached (at least partially)

to the side sills, which allowed the structure of

car 3191 to transmit inertial forces to the end

underframe of car 3252 that were greater than it

received. As a result, the body and some

detached sections of the underframe of car 3252

continued forward after the initial impact. This

forward motion, combined with the outward

movement of the side sills, allowed the body

shell of car 3252 to telescope outside the body

of car 3191. As the collision progressed, the end

underframe of 3252 began to act as a steel

bumper for car 3191, buckling the floor of car

3252 and causing the remaining components of

the car’s underframe to fail. By the time car

3252 came to rest, it had telescoped

approximately 21 feet over the body of 3191,

and its occupant volume had been severely

compromised.

The compromised passenger space in car

3252 is a serious safety concern. This accident

occurred on a weekend evening when the

accident train was carrying only two passengers

in the rear of the train, but it could have

happened during a weekday rush hour to a train

carrying hundreds of commuters. Many of those

passengers who would have been occupying the

front portion of the first car would probably

have received fatal injuries, and scores more

throughout the train could have been injured

seriously. The Safety Board concludes that the

design of Metrorail cars may make them

susceptible to telescoping in collisions that

involve a failure of the attachments securing the

end underframe to the side sills.

The Safety Board believes that WMATA

should undertake, with the assistance of

qualified engineering support, a comprehensive

evaluation of the design and design

specifications of all series of Metrorail cars with

respect to resisting carbody telescoping and

providing better passenger protection, and that it

should make the necessary modifications, such

as incorporating underframe bracing or similar

features, to improve the crashworthiness of cars

in the current and/or future Metrorail fleet.

Station/Platform Overruns on the

Metrorail System

The highly computerized Metrorail ATC

system is designed to bring trains to a stop at the

appropriate station marker. Nonetheless,

Metrorail experiences an average of 400 to 450

station or platform overruns each year. The

Safety Board is concerned that this large number

of station overruns indicates the presence of an

uncorrected deficiency in that part of the

Metrorail ATC system that is designed to detect

a train’s location in relation to a station

platform. Metrorail officials have stated that

they consider overruns of the type normally

experienced on the Metrorail system to be a

service issue (an inconvenience to passengers)

rather than a safety issue. This could explain
66

Metrorail management’s failure to conduct a

detailed analysis of the overruns so that the

underlying deficiency or deficiencies can be

corrected. As shown by this accident, however,

under certain circumstances a platform overrun

of only one car can have serious safety

implications. The Safety Board concludes that

because WMATA management has not viewed

station overruns as a potential

safety issue, it has not taken the adequate steps

to identify and eliminate the cause of the 400 to

450 station or platform overruns experienced on

the Metrorail system each year. The Safety

Board believes that WMATA should conduct a

detailed investigation and analysis to determine

the cause of the overruns and should take the

measures necessary to improve station stopping

accuracy.
CONCLUSIONS

1. Neither fatigue nor track and signal

operations were causal or contributing

factors in this accident.

2. The Washington Metropolitan Area Transit

Authority (WMATA) decision to

completely and suddenly replace its policy

of intermittent routine manual train

operation with an essentially untested policy

of full-time automatic train operation was a

hasty decision based on insufficient

information.

3. WMATA, before making the decision to

eliminate manual train operation on the

Metrorail system, failed to consider the

continuing need for train operators to

maintain proficiency in manual train

operation.

4. Metrorail management failed to fully

understand the design features and

limitations of the automatic train control

system, which led to unjustified

management confidence that the system

could ensure safe train operation under all

operating conditions.

5. WMATA management, prior to the

accident, did not have a well-thought-out,

firmly established maximum authorized

speed policy that was understood and

followed by all operating department

employees.

6. Under extreme low-adhesion conditions, the

deceleration rates provided by the

Westinghouse Air Brake Company H-1

slip/slide control unit on Metrorail 3000-

series cars and specified in WMATA

specifications result in stopping distances

that are longer than can be safely

accommodated by the automatic train

control block design.

7. WMATA at the time of the accident was

using the non-safety-critical automatic train

supervision subsystem to perform safetycritical functions.

8. The November 17, 1995, notice instructing

Operations Control Center controllers that

they were not to permit train operators to

change from automatic to manual mode

constituted a change to Metrorail Safety

Rules and Procedures Handbook rule 3.85,

and in issuing the notice, WMATA

management failed to comply with its own

established formal procedures for making

changes to operating rules.

9. If WMATA management had initially

issued written, rather than oral, instructions

regarding the safe placement of gap trains

and had ensured that this policy was known

and followed, the gap train at Shady Grove

would probably not have been located

where it was on the night of the accident,

and the collision would not have occurred.

10. WMATA management relies too heavily on

oral instructions to convey operations and

safety information to its managers,

supervisors, and employees.

11. WMATA management and its board of

directors, at the time of this accident, was

not providing adequate direction to ensure

safety on the Metrorail system.

12. As demonstrated by this accident, the

training given to Operations Control Center

controllers by WMATA prior to the

accident was inadequate to prepare them to

safely manage and control the highly

automated Metrorail system.

13. Operations Control Center controllers, and,

to a degree, their immediate supervisors,

had responsibility for day-to-day train

operations, but they lacked the authority and

the systematic procedures necessary to

effectively carry out that responsibility.

14. The deficient performance of the Operations

Control Center on the night of the accident

resulted from top-level WMATA

management policies and decisions in that

Metrorail management did not create an
68

environment in which controllers were

encouraged to use their own experience,

knowledge, and judgment to make decisions

involving the safety of Metrorail operations.

15. The evidence is insufficient to indicate

whether the train operator activated the

emergency stop button before impact, but if

he did activate emergency braking, he did so

too late to avoid the collision.

16. The accident train operator acted in

accordance with his limited experience

when he followed Operations Control

Center instructions and did not undertake

unilateral and exceptional action to stop his

train.

17. The train operator probably did not suffer

any of the possible side effects associated

with the use of Tylenol 3.

18. Third-rail schematics would have aided

firefighters in the placement of their

warning strobe and alarm devices and would

have helped ensure safe movement of rescue

personnel throughout the accident area.

19. The number of warning strobe and alarm

devices that was delivered to the accident

site was insufficient to fully protect

emergency rescue personnel working in the

vicinity of the interlocking.

20. The failure of the rescue commander at the

accident scene to immediately establish a

direct command link with the Operations

Control Center caused miscommunications

and delays in deenergizing the third rail that

unnecessarily put firefighters at risk.

21. WMATA acted improperly when it did not

halt train traffic into Shady Grove and turn

off third-rail power in the accident area

immediately after the Operations Control

Center was notified of the collision.

22. The design of Metrorail cars may make

them susceptible to telescoping in collisions

that involve a failure of the attachments

securing the end underframe to the side sills.

23. Because WMATA management has not

viewed station overruns as a potential safety

issue, it has not taken the adequate steps to

identify and eliminate the cause of the 400

to 450 station or platform overruns

experienced each year on the Metrorail

system.
PROBABLE CAUSE

he Safety Board determines that the

probable cause of this accident was the

failure of Washington Metropolitan Area

Transit Authority management and board of

directors (1) to fully understand and address the

design features and incompatibilities of the

automatic train control system before

establishing automatic train operation as the

standard operating mode at all times and in all

weather conditions, (2) to permit operating

department employees, particularly Operations

Control Center controllers and supervisors, to

use their own experience, knowledge, and

judgment to make decisions involving the safety

of Metrorail operations, and (3) to effectively

promulgate and enforce a prohibition against

placing standby trains at terminal stations on the

same track as incoming trains. Contributing to

the severity of the injuries to the train operator

was the disproportionate amount of crush

sustained by the lead cars of the colliding trains.

T
RECOMMENDATIONS

As a result of its investigation of this

accident, the National Transportation Safety

Board makes the following recommendations:

To the Washington Metropolitan Area

Transit Authority:

Analyze the braking performance under

low-adhesion conditions of all railcar

series in the Metrorail fleet. Take the

measures necessary to ensure

compatibility between the cars’ braking

performance and the automatic train

control system block design. (R-96-26)

Discontinue the use of the non-vital and

non-fail-safe automatic train supervision

(ATS) subsystem to perform safetycritical functions, and make it

impossible for trains to default to a

higher speed when a lower speed is

required to ensure safe operation. (R-96-

27)

Establish management controls to

ensure that changes to Metrorail

operating policy are properly evaluated

before adoption and that any such

changes that may constitute a change in

operating rules are (1) made in

compliance with formal rule-change

procedures, and (2) fully coordinated

with all appropriate Washington

Metropolitan Area Transit Authority

technical and administrative branches

and divisions. (R-96-28)

Establish, document, and enforce a

maximum authorized speed for every

route segment on the Metrorail system.

Ensure that these speeds are made

known to all Metrorail personnel who

hold safety-sensitive positions. (R-96-

29)

Develop a formal operating rule that

governs the placement of standby gap

trains at Metrorail terminals or other

locations. This rule should clearly state

that gap trains will not be stored on the

inbound track. (R-96-30)

Develop and implement a formal,

comprehensive, recurrent training and

qualification program for Operations

Control Center controllers that includes,

at a minimum, decisionmaking,

instruction and testing on Washington

Metropolitan Area Transit Authority

rules, policies, operational procedures,

emergency procedures, emergency

preparedness and notification (including

the minimum information to be

provided to emergency dispatchers);

Metrorail signal and control systems;

and the physical characteristics of the

Metrorail system, to include

requirements that controllers be

qualified on the physical characteristics

of the route segments for which they are

responsible. (R-96-31)

Develop and implement procedures for

Operations Control Center controllers

that (1) provide for active monitoring of

both the automated control system and

revenue train operation, (2) permit

standardized interventions at the onset

of recognition of potential automated

system failures as well as direct hazards

to individual trains, and (3) include

unambiguous, clear guidelines for

recognizing emergency operating

situations requiring the stopping of

trains. (R-96-32)

Discontinue the practice of using oral

instructions to convey standard

operating procedures or to notify Metrorail personnel of new or revised rules,

policies, or operating practices. (R-96-

33)

Develop and implement procedures to

ensure that Metrorail operations

personnel receive all bulletins, special

orders, memoranda, or notices related to

their responsibilities. These procedures
71

should include a mechanism by which

these personnel must sign or initial a

document to signify that they have

received, read, and understood any

guidance intended for them. (R-96-34)

Implement policies and procedures that

provide a means for train operators to

develop and maintain proficiency in

manual train operation. (R-96-35)

Conduct a detailed investigation and

analysis to determine the cause of the

approximately 400 station or platform

overruns experienced across the Metrorail system each year, and take the

measures necessary to improve train

stopping accuracy and to eliminate

station overruns. (R-96-36)

Undertake, with the assistance of

qualified engineering support, a

comprehensive evaluation of the design

and design specifications of all series of

Metrorail cars with respect to resisting

carbody telescoping and providing

better passenger protection, and make

the necessary modifications, such as

incorporating underframe bracing or

similar features, to improve the crashworthiness of cars in the current and/or

future Metrorail fleet. (R-96-37)

Establish and administer a comprehensive educational program to alert

employees to the potential adverse

effects on performance that may arise

from the use of prescribed and over-thecounter medications. (R-96-38)

Finalize the specifications for a new advanced-technology carborne monitoring

system and, once that is complete,

retrofit existing Metrorail cars with the

monitors/recorders during rehabilitation

and require that all new Metrorail cars

be equipped with the devices. (R-96-39)

Coordinate with emergency service

providers in all jurisdictions served by

the Metrorail system to determine what

information should be provided during

an initial emergency notification, and

amend the Metrorail Safety Rules and

Procedures Handbook or standard

operating procedures as needed to

reflect these requirements. (R-96-40)

Amend Washington Metropolitan Area

Transit Authority standard operating

procedures to require that in Metrorail

emergencies in which rescue workers

must be summoned to the scene or in

which the possibility of passenger

evacuation exists, all train traffic be

diverted from that location as soon as

possible and all third-rail circuits in the

emergency area, including those on

adjacent tracks, be deenergized as soon

as trains have left the vicinity. (R-96-41)

Develop a mechanism to provide

emergency rescue personnel responding

to an accident anywhere on the

Metrorail system with easily accessible

information about third-rail circuitry.

Such a mechanism could include or

consist of posting schematics or thirdrail circuit diagrams on all blue light

boxes and fences adjacent to

interlockings. (R-96-42)

Implement a program of regularly

scheduled operational testing of systems

used to remotely trip third-rail circuit

breakers from Operations Control

Center command consoles. (R-96-43)

Increase the frequency of command and

control exercises conducted jointly

between the Washington Metropolitan

Area Transit Authority and the

emergency rescue services of all

jurisdictions served by the Metrorail

system. (R-96-44)

Coordinate with and assist fire and

rescue service providers of all

jurisdictions served by the Metrorail

system in the procurement and

distribution of sufficient quantities of

warning strobe and alarm devices

(WSADs) or similar protective devices

to ensure that all rescue stations that

may respond to a Metrorail accident are

equipped to monitor the status of thirdrail power in an accident area that
72

includes one or more interlockings. (R96-45)

To the Federal Transit Administration:

Develop, with the assistance of the

American Public Transit Association,

guidelines for monitoring/recording

devices that capture critical performance and event data for rapid rail transit

cars and urge transit agencies to install

these devices on new and rehabilitated

cars. (R-96-46)

To the American Public Transit Association:

Cooperate with the Federal Transit

Administration in developing guidelines

for monitoring/recording devices that

capture critical performance and event

data for rapid rail transit cars and urge

transit agencies to install these devices

on new and rehabilitated cars. (R-96-47)

To the Montgomery County Fire and Rescue

Commission:

Review your Metrorail Standard

Operating Procedures regarding the

requirement that the on-scene rescue

commander immediately take charge of

the accident scene and establish a direct

communications link with the Metrorail

Operations Control Center. Ensure that

all rescue personnel and supervisors are

knowledgeable about the procedure and

are trained to carry it out. (R-96-48)

To all jurisdictions providing primary or

secondary response to Metrorail accidents or

incidents:

Review the circumstances of this

accident, with particular attention to

deficiencies in emergency response

procedures. Review and amend, as

necessary, your risk assessment

procedures and emergency response

plans and procedures for responding to

Metrorail accidents or incidents. (R-96-

49)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

JAMES E. HALL

Chairman

ROBERT T. FRANCIS II

Vice Chairman

JOHN A. HAMMERSCHMIDT

Member

JOHN J. GOGLIA

Member

GEORGE W. BLACK, JR.

Member

October 29, 1996
73

APPENDIX A

Investigation

The National Transportation Safety Board learned of this accident on January 6, 1996.

Investigation by telephone began immediately. The winter storm delayed the dispatch of an onscene investigator from the Safety Board’s Washington, D.C., headquarters until January 11,

1996. Additional investigators were dispatched later to participate in the on-scene investigation.

Investigators began taking testimony on January 16, 1996.

This report is based on the factual information developed as a result of the investigation

and on Safety Board analysis. The Safety Board has considered all facts in the investigative

record relative to its statutory responsibility to determine probable cause of the accident and to

make recommendations.

The following parties participated in this investigation: Washington Area Metropolitan

Transit Authority, Westinghouse Air Brake Company, and the Rockville (Maryland) Volunteer

Fire Department.

The Safety Board did not conduct a public hearing during this investigation.

75

APPENDIX B

November 17, 1995, WMATA Notice to all OCC Personnel

NOTICE

ALL OCC PERSONNEL

● PERFORMANCE LEVEL 4 is to be implemented system wide

during the following times:

SATURDAY & SUNDAY - 0700 hours to 0900 hours

MONDAY -0400 hours to 0600 hours

. ADVERSE/INCLEMENT WEATHER CONDITIONS

Implement PERFORMANCE LEVEL 4 SYSTEM WIDE at the first

sign of rain, sleet or snow.

. AT NO TIME WILL TRAINS BE PERMITTED TO OPERATE IN A

MANUAL MODE (MODE II, LEVEL I), except in an emergency

situation.

. The requirement for trains to be operated MODE 2, LEVEL 1 for the first

trip is RESCINDED until further notice.

i

1, “;&” (.~.i L4):’7 %

Superintendent - OCCS

November 17, 1995



79

APPENDIX D

February 14, 1996, Memorandum, Subject: ATC Block Design

M]

metro

sUBJECT:

FROM:

TO:

Washington Metropolitan Area Transit Authority

MEMORANDUM ~

February 14, 1996

ATC Block Design

SYPM-M “Lukes\4_.

SARM - K. Lyons

In response to your telephone call, I have attached copies of the Sections 3.2.3,

Transit Vehicle Characteristics and 3.3.3, ATC Block Design” of Contract Specifications

1Z7013, ATC for the middle E route. Generally. these specifications provide the requirements

for a contractor to perform a block design. The Technical Appendices contain acceleration

and clearance information. They do not provide any information on braking; all the information

relative to braking is in section 3.2.3.

The safe braking distance calculations are based on 75 % of Full Service Braking (64),

which is 2.2 mphps below 50 mph and tapered from 2.2 to 1.65 mphps between 50 mph and

75 mph. This approximates a 25°A safety margin. In addition, a failure mode is inserted into

the calculations such that a train will accelerate at full power above its previous authorized

speed for a portion of the Reaction Distance. All reaction times for the equipment, which are

provided by rail car engineers, are considered to be ‘worst case.’ After the Braking Distance

is calculated, 30 feet is added for coupler overhang and jerk rate while stopping (flare-out).

The block design is safe as long as the effective brake rate of a train is equal to or

greater than 75% of Full Service Brake rate. If the effective brake rate of the train falls below

this level, then other measures must be taken to assure safe operation.

81

APPENDIX E

Signal System and Speed Command Tests

Safety Board investigators tested the Metrorail signal system and determined that, during

the test period, it functioned as designed. Safety Board investigators conducted tests to determine

if the speed commands transmitted to trains under different scenarios matched the signal design

and to determine if the accident speed scenario could be duplicated. The tests were performed on

February 21, 1996, between Twinbrook and Shady Grove stations. (See table on next page for the

speed commands received under each scenario.)

Scenario No. 1 -- Scenario No. 1 simulated the accident sequence. The purpose was to

determine what ATP and ATS speeds would be transmitted to the train as it approached the

Shady Grove passenger station with another train occupying the YL2-4 track circuit (where the

gap train stood on the night of the accident) and signal A15-38 displaying a lunar aspect. A

performance level of 8 (ATS speed 49 mph) was set at the Twinbrook station. A performance

level of 3 (ATS speed 59 mph) was set at Rockville station. At Rockville, the test train was

allowed to overrun the station platform by one car length. The right and left door circuit breakers

were de-energized to prevent the doors from opening on the lead car. The door circuit breakers

were then restored to their normal positions.

When the circuit breakers were re-energized, the test train ATS speed changed from PL-3

speed (59 mph) to the ATP speed (75 mph) because the lead car, which carried the TWC

receiver, was past the passenger station track circuit boundary. As the test train left the first block

after the Rockville station (outbound, toward Shady Grove), and the ATP speed increased to its

normal 75 mph, the ATS speed also became 75. The test scenario thus duplicated the experience

of train T-111 on the night of the accident.

Scenario No. 2 -- The second scenario was conducted to determine what speed command

would have been received if train No. T-111 had made a proper stop at the Rockville station and

had not overrun the station platform. Under this scenario, train T-111 would have been limited to

a top speed of 59 mph between the Rockville and Shady Grove stations.

Scenario No. 3 -- Scenario No. 3 was similar to scenario No. 1, except that signal A15-38

was changed to display a stop signal. After allowing the train to overrun the Rockville station

platform by one car, the test train operator keyed out and then keyed back in to simulate the

actions of the accident train operator. This action was found to cancel the performance level 3

that had been entered for the Rockville station. Because of the stop signal, the ATP and ATS

speed commands would have been reduced to 40 mph approximately 3,700 ft. from the station

platform, decreasing to 0 mph (a stop) just before the A15-08 signal, located approximately

1,000 ft. from the station platform.
82 Appendix E

Scenario No. 4 -- Scenario No. 4 was similar to scenario No. 2, except that signal A15-38

was changed to display a stop signal. By making a proper stop, the test train retained the

performance level 3 assigned to it at the Rockville station and was limited to a top speed of 59

mph. The stop signal caused the same reduced speed profile as in scenario 3.

Scenario No. 5 -- The last scenario was conducted to determine what speed command

train T-111 would have been received between the Rockville and Shady Grove stations if it had

made a proper station stop and if signal A15-38 had displayed a lunar aspect with a train

occupying the YL2-4 track circuit, but with the south interlocking switch on track 2 lined for a

crossover move to track 1. This test determined that the “reverse” switch position allowed

slightly higher speeds approaching the Shady Grove station than scenario 2. An additional test

determined that these were the same speed commands that would have been received if the

switch were in the normal (straight through) position with no gap train occupying the block.
Appendix E 83

ATP and ATS speed reception tests

Block

Number and

Length (ft.)

Train T-111 Test

Scenario No.

1

Test

Scenario No.

2

Test

Scenario No.

3

Test

Scenario No.

4

Test

Scenario No.

5

Rockville

Station ATP ATS Actual1 ATP ATS ATP ATS ATP ATS ATP ATS ATP ATS

A2-806

438 75 75 Unk 55 55 55 55 55 55 55 55 55 55

A2-811

569 75 75 38.8 75 75 75 59 75 75 75 59 75 59

A2-816

562 75 75 38.3 75 75 75 59 75 75 75 59 75 59

A2-822

1,235 75 75 49.5 75 75 75 59 75 75 75 59 75 59

A2-834

1,193 75 75 50.8 75 75 59 59 75 75 75 59 75 59

A2-846

596 75 75 68 75 75 75 59 75 75 75 59 75 59

A2-852

792 75 75 67.5 75 75 75 59 75 75 75 59 75 59

A2-860

997 75 75 67.9 75 75 75 59 75 75 75 59 75 59

A2-870

895 75 75 75 75 75 75 59 75 75 75 59 75 59

A2-879

894 75 75 75 75 75 75 59 75 75 75 59 75 59

A2-888

420 75 75 75 75 75 75 59 75 75 75 59 75 59

A2-892

1,240 75 75 75 75 75 75 59 75 75 75 59 75 59

A2-905

1,342 75 75 75 75 75 75 59 40 40 40 40 75 59

A2-918

426 55 55 72.6 55 55 55 55 40 40 40 40 55 55

A2-922

806 55 55 69 55 55 55 55 22 22 22 22 55 55

A2-930

660 35 35 56 35 35 35 35 0 0 0 0 35 35

A15-

3B/1BT

428

28 28 49 28 28 28 28 0 0 0 0 35 35

A9-941

52 28 28 352 28 28 28 28 0 0 0 0 35 35

Shady Grove

Station 15 15 45 15 15 15 15 0 0 0 0 22 22

A2-948

213 0 0 36 0 0 0 0 0 0 0 0 0 0

7BT/5BT

223 0 0 Unk 0 0 0 0 0 0 0 0 0 0

1

Average actual speed for the block calculated based on the time entered and left each block and the known length of

the block.

2

Disregard this speed because of the short block length.

APPENDIX F -- Brake Test Details

I

Results of train stopping distance tests conducted March 7,1996

,.

1 B5 30 north 739+00 741+05

2 B5 30 south 783+00 779+10 32 15.9 390 2.01

3 B4 30 north 739+00 741+05 30 12.8 205 2.34

4 B4 30 south 783+00 780+10 31 14.1 290 2.20

5*

6 B3 30 south 783+00 779+80 31 16.3 320 1.90

7 B2 30 north 739+00 742+05 30 15.5 305 1.94

8 B2 30 south 783+00 779+00 30 18.0 400 1.67

9 B5 60 north 739+00 757+00 59 38.6 1,800 1.53

10 B5 60 south 783+00 757+70 62 48.8 2,530 1.27

11 B4 60 north 739+00 758+80 60 40.9 1,980 1.47

12 B4 60 south 783+00 762+10 62 40.6 2,090 1.53

13 B3 60 north 739+00 761+30 62 44.6 2,230 1.39

14 B3 60 south 783+00 758+90 61 47.9 2,410 1.27

15 B2 60 north 739+00 759+40 60 43.1 2,040 1.39

16 B2 60 south 783+00 755+75 62 53.4 2,725 1.16

17 B5 75 north 739+00 780+00 77 64.5 4,100 1.19

18 B5 75 south 783+00 732+25 78 76 5,075 1.03

19 B4 75 north 739+00 769+25 68 54.6 3,025 1.25

20 B4 75 south 783+00 742+95 74 66.6 4,005 1.11

21 B3 75 north 739+00 772+80 74 56.7 3,380 1.31

22 B3 75 south 783+00 740+90 75 67.2 4,210 1.12

23 B2 75 north 739+00 767+05 71 50.4 2,805 1.41

24 B2 75 south 783+00 744+00 73 65.7 3,900 1.11

* Invalid Test
86 Appendix F

Results of train stopping distance tests conducted March 8, 1996

Test # Mode Solution

Applied?

PL* at

Twinbrook

PL* at

Rockville

Stopping

Distance (ft.)

1&2 Automatic No 8 3 2,897

3&4 Automatic No 1 1 2,992

5 Manual Yes Not Available 1 3,122

6 Manual Yes 1 1 1,542

7 Automatic Yes 1 3 2,992

8 Automatic Yes 1 1 3,122

*Performance level

Results of train stopping distance tests conducted March 14, 1996

Test # Mode PL1 Speed at

CCP2

(mph)

Speed at Beginning

of Shady Grove

Platform (mph)

Brake

Level

Stopping

Distance

(ft.)

1 Automatic 3 ** 27 N/A 2,822

2 Automatic 1 ** 26 N/A 2,522

2A Automatic 1 72 27 N/A 2,822

3 Manual 1 57 Short stop B5 1,492

4 Manual 1 74 48 B5 3,529

4A Manual 1 70 48 B5 3,595

4C Automatic 1 72 49 N/A 3,777

6* Automatic 1 72 28 N/A 2,672

6A* Automatic 1 71 28 N/A 2,822

8* Manual 1 72 Short stop B5 1,972

8A* Manual 1 75 Short stop B5 2,162

1

Performance level

2

Code change point (point at which a new speed command is transmitted to the train)

*Tests conducted with the new H-1 software EPROM

**Unrecorded


89

APPENDIX H

Previous Safety Recommendations Issued to WMATA

As Result of 1982 Fatal Metrorail Accident

R-82-008 Class I

The NTSB recommends that the Washington Metropolitan Area Transit Authority: modify its

operating rules and standard operating procedures to require the establishment of an absolute

block whenever it is necessary to operate a train in other than the fully automatic mode.

Status: Closed - Acceptable Action 3/18/85

R-82-009 Class I

The NTSB recommends that the Washington Metropolitan Area Transit Authority: include in its

operating rules a requirement that whenever it is necessary to operate a train manually, the

operations control center will not permit the train to proceed into the block to the next station as

long as that block is occupied by another train. If there is an interlocking between the stations,

require that the absolute block between the stations will apply to both main tracks unless the

operations control center has an oscilloscope indication that all crossover switches are aligned for

main track movement.

Status Closed - Acceptable Action 10/18/84

R-82-010 Class I

The NTSB recommends that the Washington Metropolitan Area Transit Authority: include in its

operating rules a requirement that train operators report to the operations control center whenever

they are unable to operate in the fully automatic mode, and enforce the operating rules requiring

authorization by the operations control center to change operating modes.

Status Closed - Acceptable Action 12/14/83

R-82-011 Class I

The NTSB recommends that the Washington Metropolitan Area Transit Authority: include in its

operating rules a requirement that before a manually operated train is permitted to enter a block

containing an interlocking, the operations control center must instruct the train's operator as to

the intended route for the train and receive proper acknowledgment from the operator.

Status Closed - Acceptable Action 10/18/84

R-82-012 Class I
90 Appendix H

The NTSB recommends that the Washington Metropolitan Area Transit Authority: modify its

operating rules to prohibit the reverse movement of a train within interlocking limits until it has

been established that no derailment has occurred, that switches are properly aligned, and that

there are no conflicting train movements.

Status Closed - Acceptable Action 12/15/82

R-82-013 Class I

The NTSB recommends that the Washington Metropolitan Area Transit Authority: improve the

maintenance and redundancy of the communications equipment in the operations control center

and the other Washington Metropolitan Area Transit Authority command centers to provide

continuous communications between all centers.

Status Closed - Acceptable Action 12/15/82

R-82-014 Class II

The NTSB recommends that the Washington Metropolitan Area Transit Authority: provide radio

communicating capability for the operations control center that is commensurate with peak radio

traffic demands of the expanding Washington Metropolitan Area Transit Authority rail system.

Status Closed - Acceptable Action 12/15/82

R-82-015 Class I

The NTSB recommends that the Washington Metropolitan Area Transit Authority: upgrade the

training given to rail transportation supervisors and assign them the necessary authority to

effectively supervise train operations and correctly deal with the full range of operating

situations.

Status Closed - Acceptable Action 10/24/85

R-82-016 Class I

The NTSB recommends that the Washington Metropolitan Area Transit Authority: implement a

program of mandatory periodic instruction and examination on the combined book of operating

rules and standard operating procedures, including emergency train evacuation procedures, for all

rail supervisors and train operators.

Status Closed - Acceptable Action 10/18/84

R-82-017 Class I
Appendix H 91

The NTSB recommends that the Washington Metropolitan Area Transit Authority: amend its

standard operating procedures to require the operations control center (1) require that, whenever

a train emergency which requires evacuation is known to exist at a location between stations, all

third-rail power circuits between the emergency location and the stations on each side of that

location be deenergized as soon as all other trains have cleared the area, and (2) to direct the

nearest qualified rail employee to begin the timely evacuation of passengers from the train.

Status Closed - Acceptable Action 10/18/84

R-82-018 Class I

The NTSB recommends that the Washington Metropolitan Area Transit Authority: implement a

continuing program to educate passengers on the procedures to be followed when it is necessary

to evacuate a disabled train.

Status Closed - Acceptable Action 10/24/85

R-82-055 Class I

The NTSB recommends that the Washington Metropolitan Area Transit Authority: immediately

implement an in-depth continuing program for controllers and their superiors in the Metrorail

operations control center which includes instruction in the rules, procedures, and fundamentals of

rail transit operations; familiarization with all Metrorail operations; radio protocol; and periodic

testing and certification by a professional training specialist who is knowledgeable in rail transit

operations.

Status Closed - Acceptable Action 10/24/85

R-82-056 Class II

The NTSB recommends that the Washington Metropolitan Area Transit Authority (WMATA):

establish a training department for Metrorail that is accountable to top WMATA management

and is staffed by professional specialists in this field.

Status Closed - Acceptable Action 12/14/83

R-82-057 Class II

The NTSB recommends that the Washington Metropolitan Area Transit Authority: evaluate the

quality of the curriculum, instruction, training aids, and periodic certification process of the

present Metrorail train operators' training course, and implement necessary improvements.

Status Closed - Acceptable Action 10/24/85
92 Appendix H

R-82-058 Class II

The NTSB recommends that the Washington Metropolitan Area Transit Authority: modify the

overspeed control on the Metrorail cars to enforce speed commands of the automatic train

protection subsystem to and including zero miles per hour.

Status Closed - Unacceptable Action 12/14/83

R-82-059 Class II

The NTSB recommends that the Washington Metropolitan Area Transit Authority: change the

identification numbers of its interlockings and interlocking signals to eliminate possible

misunderstandings which could result in a train improperly passing a restricting signal.

Status Closed - Unacceptable Action 12/15/82

R-82-060 Class II

The NTSB recommends that the Washington Metropolitan Area Transit Authority: require the

Metrorail operations control center personnel, rail transportation supervisors, and train operators

to refer to all signals by their complete and proper designation.

Status Closed - Acceptable Action 12/15/82

R-82-061 Class I

The NTSB recommends that the Washington Metropolitan Area Transit Authority: require that

the Metrorail operations control center personnel, and transportation supervisors understand and

implement provisions of standard operating procedure No. 15 for the establishment of an

absolute block when there is a failure in the automatic train control system.

Status Closed - Acceptable Action 12/15/82

R-82-062 Class II

The NTSB recommends that the Washington Metropolitan Area Transit Authority: include in

Metrorail operating rules a definition of restricted speed. Establish and require that all

employees involved in the operation of trains understand and abide by the maximum allowable

speed for trains being operated through an interlocking with inoperative track circuits.

Status Closed - Acceptable Action 12/14/83

R-82-063 Class I
Appendix H 93

The NTSB recommends that the Washington Metropolitan Area Transit Authority: eliminate the

practice of issuing verbal instructions to the Metrorail operations control center personnel which

modify or amend operating rules and standard operating procedures.

Status Closed - Acceptable Action 12/15/82

R-82-064 Class II

The NTSB recommends that the Washington Metropolitan Area Transit Authority: modify the

automated alert system to segregate the "serious" physical plant-related type 1 visual alarms from

the less serious train-oriented type 2 alarms, and to provide an audible indication of a type 1

alarm which must be manually acknowledged.

Status Closed - Acceptable Action 12/14/83

R-82-065 Class II

The NTSB recommends that the Washington Metropolitan Area Transit Authority: require that

type 1 automated alert alarms be immediately reported by the operations control center to

maintenance control for corrective action.

Status Closed - Acceptable Action 12/15/82

R-82-066 Class II

The NTSB recommends that the Washington Metropolitan Area Transit Authority: require that

maintenance forces inspect switch machine fusetrons while making their regular preventive

maintenance inspections of the control system apparatus.

Status Closed - Acceptable Action 10/18/84

R-82-067 Class II

The NTSB recommends that the Washington Metropolitan Area Transit Authority: provide train

operators with some type of self-contained radios which will function in the event that auxiliary

and emergency car power sources are lost.

Status Closed - Acceptable Action 12/14/83

R-82-068 Class II

The NTSB recommends that the Washington Metropolitan Area Transit Authority: arrange for a

comprehensive review of its Metrorail safety program and of its rules and procedures by a peer

review board of the American Public Transit Association.

Status Closed - Acceptable Action 12/15/82
94 Appendix H

R-82-069 Class II

The NTSB recommends that the Washington Metropolitan Area Transit Authority: provide all

Metrorail operations control center controllers and their supervisors with clear instructions that

all automatic reclosing circuit breakers for the traction power sections in the affected area must

be commanded open prior to the commencement of an evacuation of a train.

Status Closed - Acceptable Action 12/15/82

R-82-070 Class II

The NTSB recommends that the Washington Metropolitan Area Transit Authority: require the

installation of an adequate number of marked emergency escape windows on all new Metrorail

cars and implement a program to similarly retrofit existing cars.

Status Closed - Acceptable Alternate Action 10/24/85

R-82-071 Class II

The NTSB recommends that the Washington Metropolitan Area Transit Authority: equip each

Metrorail car with an adequate number of self-contained, battery-powered emergency lights

which will automatically illuminate the car interior in the event the car's auxiliary and emergency

power is lost.

Status Closed - Unacceptable Action 10/18/84

R-82-072 Class II

The NTSB recommends that the Washington Metropolitan Area Transit Authority: post

emergency information inside Metrorail cars at locations near the doors regarding the location

and method of operation of the manual emergency door handle.

Status Closed - Acceptable Alternate Action 10/24/85

R-82-073 Class II

The NTSB recommends that the Washington Metropolitan Area Transit Authority: retrofit

existing Metrorail cars with derailment detector devices which will apply the brakes in

emergency when a car wheel leaves the rail. Require that all new cars be so equipped.

Status Closed - Unacceptable Action 10/18/84
Appendix H 95

R-82-074 Class II

The NTSB recommends that the Washington Metropolitan Area Transit Authority: maintain the

carborne monitors on existing Metrorail cars and require their installation on cars presently on

order. Acquire the necessary equipment to read the monitor tapes.

Status Closed - Acceptable Action 4/22/91

R-82-075 Class II

The NTSB recommends that the Washington Metropolitan Area Transit Authority: provide a

portable radio, compatible with the Metrorail communication system, at each station kiosk for

dedicated use by fire/rescue personnel.

Status Closed - Acceptable Alternate Action 12/14/83

R-82-076 Class II

The NTSB recommends that the Washington Metropolitan Area Transit Authority: expedite the

completion of its underground communication system.

Status Closed - Acceptable Action 12/14/83

R-82-077 Class II

The NTSB recommends that the Washington Metropolitan Area Transit Authority: in

conjunction with the District Of Columbia fire department, expand the scope and frequency of

the disaster crash simulations and include hospitals and fire/rescue units from surrounding

jurisdictions.

Status Closed - Acceptable Action 12/14/83