Safety Recommendations target Washington Transit Authority.

Press Release Summary:



According to NTSB, Washington Metropolitan Area Transit Authority should establish inspection and maintenance procedures to examine audio frequency track circuit modules within Metrorail system to identify and remove modules that exhibit pulse-type parasitic oscillation. They should also conduct safety analysis of Metrorail automatic train control system, implement cable insulation resistance testing, and replace 1000-series railcars with cars that have crashworthiness collision protection.



Original Press Release:



NTSB Safety Recommendations R-10-8 through -22



The National Transportation Safety Board makes the following safety recommendations to the Washington Metropolitan Area Transit Authority:

Because of the susceptibility to pulse-type parasitic oscillation that can cause a loss of train detection by the Generation 2 General Railway Signal Company audio frequency track circuit modules, establish a program to permanently remove from service all of these modules within the Metrorail system. (R-10-8)

Establish periodic inspection and maintenance procedures to examine all audio frequency track circuit modules within the Metrorail system to identify and remove from service any modules that exhibit pulse-type parasitic oscillation. (R-10-9)

Review the process by which Metrorail technical bulletins and other safety information are provided to employees and revise that process as necessary to ensure that (1) employees have received the information intended for them, (2) employees understand the actions to be taken in response to the information, and (3) employees take the appropriate actions. (R-10-10)

Completely remove the unnecessary Metrorail wayside maintenance communication system to eliminate its potential for interfering with the proper functioning of the train control system. (R-10-11)

Conduct a comprehensive safety analysis of the Metrorail automatic train control system to evaluate all foreseeable failures of this system that could result in a loss of train separation, and work with your train control equipment manufacturers to address in that analysis all potential failure modes that could cause a loss of train detection, including parasitic oscillation, cable faults and placement, and corrugated rail. (R-10-12)

Based on the findings of the safety analysis recommended in R-10-12 incorporate the design, operational, and maintenance controls necessary to address potential failures in the automatic train control system. (R-10-13)

Implement cable insulation resistance testing as part of Metrorail's periodic maintenance program. (R-10-14)

Work with the Tri-State Oversight Committee to satisfactorily address the recommendations contained in the Federal Transit Administration's March 4, 2010, final report of its audit of the Tri-State Oversight Committee and the Washington Metropolitan Area Transit Authority. (R-10-15)

Require that your safety department; representatives of the operations, maintenance, and engineering departments; and representatives of labor organizations regularly review recorded operational data from Metrorail train onboard recorders and the Advanced Information Management system to identify safety issues and trends and share the results across all divisions of your organization. (R-10-16)

Develop and implement a non-punitive safety reporting program to collect reports from employees in all divisions within your organization, and ensure that the safety department; representatives of the operations, maintenance, and engineering departments; and representatives of labor organizations regularly review these reports and share the results of those reviews across all divisions of your organization. (R-10-17)

Review the Hazard Identification and Resolution Matrix process in your system safety program plan to ensure that safety-critical systems such as the automatic train control system and its subsystem components are assigned appropriate levels of risk in light of the issues identified in this accident. (R-10-18)

Develop a formal process by which the general manager and managers responsible for Washington Metropolitan Area Transit Authority operations, maintenance, and engineering will periodically review, in collaboration with the chief safety officer, all safety audits and open corrective action plans, and modify policy, identify and commit resources, and initiate any other action necessary to ensure that the plans are adequately addressed and closed within the required time frame. (R-10-19)

Remove all 1000-series railcars as soon as possible and replace them with cars that have crashworthiness collision protection at least comparable to the 6000-series railcars. (R-10-20)

Ensure that the lead married-pair car set of each train is equipped with an operating onboard event recorder. (R-10-21)

Develop and implement a program to monitor the performance of onboard event recorders and ensure they are functioning properly. (R-10-22)

http://ntsb.gov/recs/letters/2010/R-10-008-022.pdf

The complete recommendation letter is available on the Web at the URL indicated above.

The letter is in the Portable Document Format (PDF) and can be read using the Acrobat Reader 5.0 or later from Adobe (http://www.adobe.com/prodindex/acrobat/readstep.html).

An archive of recommendation letters is available at www.ntsb.gov/recs/letters/letters.htm.

Electronic versions of letters may or may not include enclosures; however, related publications, accident briefs, and aviation accident synopses may be found on the NTSB website.

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