[Congressional Record Volume 156, Number 118 (Thursday, August 5, 2010)]
[Senate]
[Pages S6867-S6868]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
FINDINGS OF THE NTSB
Mr. CARDIN. Mr. President, I rise today to discuss the findings of
the National Transportation Safety Board's final report on its
investigation into the fatal June 22, 2009, Metrorail crash on the Red
Line near Fort Totten.
This report is a call to action for Congress to pass legislation that
will help prevent such tragedies on our Nation's public transit systems
from ever happening again.
Last week, the NTSB presented the findings of its year-long
investigation into last year's Metrorail crash that killed eight
passengers and the train's conductor nine total. The fatal accident
also hospitalized 52 passengers with serious injuries and left
approximately 30 others with minor injuries.
The investigation concluded:
The cause of the crash was a series of faulty track
circuits that failed to detect the presence of a stopped
train on the right-of-way.
The severity of the accident was compounded by the poor
crashworthiness of the 30-plus year-old railcars involved in
the accident where most of the injuries and fatalities
occurred.
Lastly, NTSB determined that safety has not been a priority
for WMATA. Simply put, Metro lacks a ``Culture of Safety''
throughout its entire organization.
NTSB Chairman Deborah Hersman aptly put it in her statement regarding
the release of its findings: ``Metro was on a collision course long
before this accident. The only question was when Metro would have
another accident--and of what magnitude.''
The root cause of the crash was a faulty track circuit that failed to
detect the presence of a train pulling into Fort Totten Station.
As a result, the system did not signal a second approaching train to
hold at a safe distance on the track.
When working properly, the track circuits are designed to detect and
trace the presence of trains on the right-of-way. This effectively
prevents two trains from occupying the same stretch of track at the
same time.
A particularly troubling finding of the NTSB's investigation is that
a 2005 ``near accident'' on the Orange and Blue lines' in the Potomac
River tunnel coming into the Rosslyn Station was caused by an identical
track circuit malfunction to the one that caused the June 22 crash.
In other words, Metro knew, from firsthand experience, about the
serious risks track circuit failures present.
The NTSB concluded that if WMATA had taken a lesson from the 2005
``near accident'' at Rosslyn and made fixing the track circuit failures
throughout the system a priority, the June 22, 2009, tragedy would have
been avoided entirely.
The second layer of safety meant to prevent a crash in the case of a
track circuit failure are automatic alerts sent to Metro Central
Command to alert control officers when a track circuit failures occurs.
However, ignoring these warnings were part of Metro's operational
protocol.
The NTSB reported that prior to the Red Line crash, track circuit
failures were such a frequent occurrence, that Central Command was
receiving an average of 3,000 system alerts a week.
Central Command's response to the overwhelming number of alerts was
to implement an automatic override program.
The override allowed Metro to operate around the alerts, rather than
fixing the circuit failures triggering the alerts.
The constant barrage of alerts ended up creating a culture of
complacency rather than creating a culture of urgency.
This negligent managerial approach to solving the warning rather than
solving the problem is entirely irresponsible and exemplifies the lack
of a Safety Culture at Metro.
Because the approaching train was under automatic control it was
completely reliant on receiving the correct operations signals from the
track circuits.
Since the system failed, it was on the train's conductor to stop the
train. The investigation concluded that operator Jeanice McMillan, of
Fairfax, VA, acted quickly and appropriately to do all she could to
stop the train.
The curvature of the track, combined with the high speed that the
automatic controls had her train travelling at, made it impossible for
Ms. McMillan to prevent her train from striking the train ahead.
Based on the emergency brake marks on the tracks, Operator McMillan
acted as soon as she had visual contact with the train ahead.
She made a selfless choice to remain at her post and do everything
she could
[[Page S6868]]
to slow the train, even when she surely must have realized that a
collision was inevitable.
Operator McMillan gave her life to save her passengers. Ms.
McMillan's heroism surely prevented an even greater tragedy and for
that we are all grateful.
The NTSB pointed to the crashworthiness of the railcars as a major
contributing factor in the severity of the accident.
These are the first-generation 1000 series cars that are subject to
shearing in crash situations.
Metro has known about the compromised crashworthiness of its oldest
railcars for many years.
A relatively low-speed accident at the Woodley Park Station in 2004
demonstrated how dangerous these railcars are in a crash situation.
Fortunately, in that accident no one was seriously injured.
After the June 22 accident, Metro implemented a plan to place the
older 1000 series cars in the center of trains as claiming that this
shelters the older, less crashworthy cars in an accident.
The NTSB has pointed out that there is no factual basis for this
practice, known as ``bellying,'' in creating safer trains.
The only way to make for safer trains is to get the old, unsafe
railcars off the system. I am happy to report, that WMATA is working to
replace the 1000 series cars incrementally with newer, safer cars.
In fact, last Monday, Metro announced it has placed the order for the
7000 series cars that will finally replace all of the oldest, most
unsafe, railcars on the system.
The NTSB's top-line recommendations to the Washington Metropolitan
Area Transit Authority are the following:
Expedite the detection and replacement of all faulty track
circuits within the System.
Expedite the replacement or reinforcement of all of the
oldest least crashworthy railcars in operation.
Ensure that all new and current railcar cockpits are
outfitted with event data recorders.
And lastly, management, starting with the board, must
establish a culture of safety that pervades the entire
organization.
The last point is incredibly important because despite Metro's
ongoing budget woes, making safety a genuine priority would come at no
additional cost to WMATA.
The NTSB also had many compelling recommendations for how the Federal
Transit Administration should establish better safety guidance.
Because of Metro's unique relationship with the Federal Government,
the FTA should provide immediate guidance to Metro on improving the
safety of its operation.
Because the FTA has no actual regulatory authority, Congress must
take the NTSB's safety improvement recommendations as a call for
legislative action.
We must act to ensure that the NTSB's recommendations to FTA can be
implemented in a way that achieves results.
Senators Dodd, Menendez, Mikulski, and I introduced legislation
requiring the Transportation Secretary to establish and implement a
comprehensive transit Public Transportation Safety program.
With the support of Senator Shelby, this bill was reported out of
committee and is awaiting action on the floor.
This legislation will give the FTA the ability to take decisive
actions such as conducting inspections, investigations, audits,
examinations of public transit systems.
The Public Transportation Safety Program Act of 2010 came about at
the request of the President and Transportation Secretary LaHood.
I applaud the Obama administration for recognizing the need to give
the FTA legal enforcement authority of its standards and rules.
This legislation establishes the type of safety enforcement authority
for the FTA that currently exists for the Federal Railroad
Administration's over commuter rail systems and that the Federal Motor
Carrier Safety Administration has for commercial trucking.
It makes sense for public transit systems that receive federal
funding to meet federal safety requirements set by the FTA.
These are safety requirements that could have saved the lives lost in
last year's Red Line crash and would help make transit systems across
the country safer for all users.
Just as I believe that the Federal Government has a role in ensuring
Metro is safe for its riders and employees, I also believe the Federal
Government has a responsibility to help fund the safe operation of the
system since Metro provides the Federal Government and its employees a
vital transportation service.
I was proud to work alongside Senators Mikulski, Webb and former
Senator John Warner to include major new funding authorization for
Metro in the Federal Rail Safety Improvement Act, which was signed into
law in 2008.
This law authorizes $1.5 billion over 10 years in federal funds for
WMATA, and is matched dollar-for-dollar by the local jurisdictions, for
capital improvements.
This arrangement will finally provide Metro with the dedicated
funding the system needs.
President Obama's fiscal year 2011 budget request to Congress
includes $150 million for Metro.
This builds on the substantial downpayment Senators Mikulski, Webb,
Mark Warner and I were able to secure for Metro last year. I am happy
to see that the Appropriations Committee has included this request in
the Transportation appropriations bill reported out of Committee.
This is an important investment, but it is not nearly enough to
fulfill all of Metrorail's obligations.
Metro maintains a list of ready-to-go projects totaling about $530
million and $11 billion in capital funding needs over the next decade.
When Metro was a relatively new system it was the epitome of safe and
reliable public transit.
After 34 years of operation, and a managerial focus on system
expansion rather than system preservation, the backlog of maintenance
needs have taken its toll.
I find it unacceptable that the transit system in our Nation's
Capital does not have enough resources to improve safety and maintain
its aging infrastructure.
My deepest sympathies remain with the families and friends whose
lives are forever affected having lost someone dear to them in last
year's tragedy.
I want them to know that you and the loved ones you lost are not
forgotten.
This tragedy has served as a constant reminder and inspiration for my
work to fix the problems that led to the tragedy.
I call on my colleagues to honor the memory of those by working to
pass the Public Transit Safety Act so that we can prevent similar
tragedies from happening in the future.
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