[Congressional Record (Bound Edition), Volume 156 (2010), Part 11]
[Senate]
[Pages 15281-15282]
[From the U.S. 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.

[[Page 15282]]

  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 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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