NTSB executive summary of report on Yellow Line smoke incident

Metro’s ‘ineffective’ practices led to deadly smoke incident, NTSB finds

Executive Summary

On January 12, 2015, at 3:15 pm. eastern standard time, Washington
Metropolitan Area Transit Authority (WMATA) southbound Yellow Line train 302, with
about 380 passengers on board, stopped after encountering heavy smoke in the tunnel
between the L?Enfant Plaza station and the Potomac River bridge in Washington, DC.
The operator of train 302 told the Rail Operations Control Center (ROCC) that the train
was ?lling with smoke and he needed to return to the station. The WMATA ROCC
allowed train 510, following train 302, to enter the L?Enfant Plaza station, which also
was ?lling with smoke. Train 302 was unable to return to the station before power to the
electri?ed third rail, which supplied the train?s propulsion power, was lost. Some
passengers on train 302 evacuated the train on their own, and others were assisted in
evacuating by ?rst responders from the District of Columbia Fire and Emergency
Medical Services Department (FEMS). As a result of the accident, 91 people were
injured, including passengers, emergency responders, and WMATA employees, and one

passenger died. WMATA estimated the total damages to be $120,000.

The National Transportation Safety Board (NTSB) has been concerned with the
safety of the WMATA rail system since 1970, when it conducted a special study of the
proposed transit rail system while it was still under construction. The resulting report,
70/1, Study of Washington Metropolitan Area. Transit Authority ?5 Safety
Procedures for the Proposed Metro System, resulted in one safety recommendation to
WMATA to ?develop the capability within WMATA for system safety engineering and

apply system safety principles to all aspects of the proposed [rail] system to identify,

assess, and correct those de?ciencies identi?ed by the analysis.? This accident is the 13th

WMATA rail accident investigated by the NSTB since WMATA rail began operation in

1976. The NTSB has issued 101 safety recommendations to WMATA since 1970.

Our investigation of this accident revealed a range of safety issues and conditions

at WMATA that illustrate the transit organization?s lack of a safety culture:

WMATA response to smoke report. A smoke detector near the location of the
heavy smoke activated at 3 :04 pm. but was not displayed at the Rail Operations
Control Center (ROCC) because of a loose wire that prevented communication
with the Advanced Information Management System. Other nearby smoke
detectors activated later, and those were displayed at the ROCC, but WMATA
had no procedures for response to smoke detector activations.
standard operating procedure states that at the ?rst report of smoke, all trains
should be stopped in both directions, but this did not happen on the day of the
accident. Instead, the ROCC told the operator of a train carrying revenue
passengers to look for smoke, which was routine response to reports

of smoke or ?re.

Tunnel ventilation. The WMATA station and tunnel ventilation systems were
designed in the 19705 when no industry standard existed for emergency
ventilations for subway transit systems. The systems were designed for heat
removal and temperature control, not for emergency smoke removal. Over the
years since WMATA began operation. several studies have identi?ed the need for

emergency smoke removal and have recommended increasing the capacity of

ventilation fans. Investigators learned that control operators in the ROCC were
not trained on strategies for con?guring station and tunnel ventilation fans, and
therefore, on the day of the accident, the under-platform fans in the L?Enfant
Plaza station were turned on in exhaust mode, blanketng train 302 in smoke and

pulling smoke into the station.

Railcar ventilation. WMATA did not instruct train operators how to shut down
the railcar ventilation systems because there was no written procedure. In
addition, operators had to ask the ROCC for permission to shut them down, and
then the ROCC provided the speci?c steps to the train operators. However, those
steps did not shut down all the ventilation systems on all the cars immediately.
Therefore, on the day of the accident, smoke was pulled into most of the railcars

on train 302 through the fresh air intakes.

Emergency response. On the day of the accident, the District of Columbia Of?ce
of Uni?ed Communications, which maintains the 911 emergency call system, was
slow in did not expediently processing the ?rst 911 call reporting the smoke. First
responders reported that when they arrived at the L?Enfant Plaza station, they
were directed to the wrong tunnel to look for train 302. Evacuating passengers
reported that egress through the tunnel was dif?cult because of dim lighting and
obstacles along the safety walkway. The FEMS incident commander appeared to
ignore the WMATA Metro Transit Police incident commander and did not take
into account the multiple agencies involved in the response and the consequent

need for elevation to a Uni?ed Command structure.

Oversight and Management. In the years since the 2009 accident at Fort Totten,
substantial improvements have not been made, and many of the same safety
management de?ciencies remain today. The Tri-State Oversight Committee has
lacked suf?cient resources, technical capacity, and enforcement authority to
provide the level of oversight needed to ensure safety at WMATA. The Tri-State
Oversight Committee also has not met the requirements of the Moving Ahead for
Progress in the let Century Act (MAP-21) that was enacted in 2012. This
accident also identified de?ciencies in the safety oversight of WMATA by the

Federal Transit Administration.

As a result of this accident, the NTSB issues safety recommendations to the
Federal Transit Administration, the mayor of the District of Columbia, the District of
Columbia Of?ce of Uni?ed Communications, the District of Columbia Fire and
Emergency Medical Services Department, the National Capital Region Emergency

Preparedness Council, and the Washington Metropolitan Area Transit Authority.

Findings

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Electrical are tracking was aided by the presence of contaminants and moisture on

third rail cables and inside cable connector assemblies.

The Washington Metropolitan Area Transit Authority?s third rail electrical power
cable systems are susceptible to electrical are tracking at improperly constructed
power cable connector assemblies, which can lead to short circuits that can generate

?re and smoke in tunnels.

The electrical short circuit initiated from either the consumed or the damaged cable

connector assembly.

Intrusion of water at the electrical arcing site contributed to the severity of the

accident.

The electrical arcing that resulted in the consumption of the cables that were resting

against the tunnel wall was the origin of the smoke at the accident location.

Including leak inspections with Washington Metropolitan Area Transit Authority

tunnel structural inspections was not effective in identifying leaks.

The Washington Metropolitan Area Transit Authority tunnel repair program was not
effective in mitigating recurring water intrusion like that found in the southbound

Yellow Line tunnel.

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Water intrusion into the Yellow Line tunnel south of L?Enfant Plaza predated the
adjacent construction of the Wharf project, and therefore the construction was not a

factor in the initiation of the electrical arcing.

The Washington Metropolitan Area Transit Authority did not have a written
procedure for operating ventilation fans in reSponse to smoke and ?re events in a

tunnel.

The Washington Metropolitan Area Transit Authority did not have effective training

on the proper operation of tunnel ventilation fans.

The Washington Metropolitan Area Transit Authority failed to address the capacity

problems of the ventilation system that were identi?ed by engineering studies.

Had the maintenance procedures in place at the time of the accident been followed
correctly, the fault in the remote control of the fans could have been identified and

corrected during the scheduled inspection.

The conditions discovered after the accident?the inability to execute remote
commands to the tunnel ventilation system, the tripped overload breakers, the
defective remote terminal unit card, and the de?cient automatic transfer switch,
automatic voltage regulator, and motor control center??resulted from the Washington

Metropolitan Area Transit Authority?s inadequate maintenance.

The Washington Metropolitan Area Transit Authority did not comply with its

ventilation fan inspection and maintenance. procedures.

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The Washington Metropolitan Area Transit Authority was not following its tunnel

washing and insulator cleaning procedure.

At the time of the accident the Washington Metropolitan Area Transit Authority did
not have a procedure for train operators to follow that would immediately shut down

the ventilation systems on all the railcars in a train.

When the operator of train 302 shut down the ventilation system, only the ventilation
system on the leading railcar shut down immediately, and the ventilation systems of

all the other railcars remained operational.

The requirement for a train operator to receive permission from the Rail Operations
Control Center to shut down the ventilation systems on a train, and the lack of a
procedure for shutting down all the ventilation systems on a train from the lead

railcar, contributed to the smoke entering the railcars in train 302.

The Rail Operations Control Center supervisor failed to ensure that the emergency
procedures contained in Standard Operating Procedure #6 were followed by the

control operators.

Had the Washington Metropolitan Area Transit Authority followed its standard
operating procedures and stopped all trains at the first report of smoke, train 302

would not have been trapped in the smoke-?lled tunnel.

The Washington Metropolitan Area Transit Authority put passengers at risk by

routinely using trains with revenue passengers to investigate reports of smoke or fire

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The Rail Operations Control Center supervisor failed to ensure that all trains in both
directions were stopped after smoke was reported, which was inconsistent with the

Washington Metropolitan Area Transit Authority standard operating procedure.

Rail Operations Control Center supervisors and control operators were not pro?cient

in executing emergency response procedures.

The Public Service Radio System communication problems were identi?ed but not

remediated before the accident.

The Washington Metropolitan Area Transit Authority?s radio?testing procedure in
place at the time of the accident was insuf?cient to identify Public Service Radio

System communication problems in a timely manner.

Communications between the District of Columbia Fire and Emergency Medical
Services Department (FEMS) liaison in the Rail Operations Control Center and the

FEMS incident commander were delayed and inef?cient.

The District of Columbia Of?ce of Uni?ed Communications? call processing delayed

the emergency response to the accident.

Without line identi?cation and direction signage at tunnel entrances and in tunnels,
emergency response personnel may have dif?culty navigating, which may delay their

response efforts.

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The lack of emergency lighting in the tunnel and the conduit and junction boxes on
the tunnel wall above the walkway were safety hazards to passengers evacuating

through the tunnel.

The lack of safety standards or regulation addressing emergency evacuation routes,
including design and lighting, led to obstructed and poorly illuminated walkways at
the Washington Metropolitan Area Transit Authority that increased the risk of injury

to people evacuating train 302 in the Yellow Line tunnel.

The lack of formal training criteria for the battalion chief position may pose

unnecessary risk with respect to incidents requiring the incident command process.

The incident commander had not been effectively trained in the skills and practices of

the incident command process.

The incident commander should have elevated the incident response to a Uni?ed

Command structure.

In the initial phase of the emergency response, the incident commander did not take
appropriate immediate action to provide emergency assistance to passengers on

train 302.

Quarterly emergency response drills, particularly those in tunnels, would better
prepare Washington Metropolitan Area Transit Authority (WMATA) and local

emergency response agencies to respond to emergencies 011 the WMATA system.

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The District of Columbia Fire and Emergency Medical Services Department was
unprepared to respond to a mass casualty event in the Washington Metropolitan Area

Transit Authority?s underground system.

The Washington Metropolitan Area Transit Authority missed the opportunity to
improve its emergency response and procedures by not conducting an after-action

review of its emergency response to the accident.

The Federal Transit Administration is not prepared to conduct direct safety oversight

of rail transit systems.

The structure of the Tri-State Oversight Committee (TOC) Executive Committee and
its failure to effectively guide the TOC reduced the ability of the TOC to execute
ef?cient and effective safety oversight of the Washington Metropolitan Area Transit

Authority.

The projected establishment of the Metro Safety Commission will be delayed by the

required legislation.

The Washington Metropolitan Area Transit Authority is not adequately bene?tting
from the safety lessons in National Transportation Safety Board accident

investigation reports and safety studies.

Although the Washington Metropolitan Area Transit Authority has taken steps to
improve its organizational safety since the 2009 Fort Totten accident, signi?cant

safety management de?ciencies still exist within the organization.

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43. An effective quality assurance program that includes audits of procedure compliance
would proactively identify Washington Metropolitan Area Transit Authority safety

de?ciencies.

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