Washington Metropolitan Area Transit Authority Red Signal Violations (RSV) Grosvenor Station Center Pocket Track June 20 and 27, 2012 Safety and Security Committee July 12, 2012
RSV Incident June 20, 2012 4:42 pm - 8-car consist passes red signal at Grosvenor center track w/o authorization during turn-back* process Post incident - Operator taken out-ofservice Trains were turned back at various points to support revenue service 5:57 pm - Train service restored to normal operations on both tracks at Grosvenor *No passengers on train during either incident 2
RSV Incident June 27, 2012 5:45 pm - 8-car consist passes red signal at Grosvenor center track w/o authorization during turn-back* process Post incident - Operator taken out of service Trains were single-tracked between Twinbrook and Medical Center Stations 6:38 pm - Train service restored to normal operations on both tracks at Grosvenor 3
Grosvenor Pocket Track Diagram OUTBOUND A11 INTERLOCKING INBOUND 32 TRACK 2 42 30 40 34 POCKET TRACK 44 Grosvenor Sta ation Platform 28 38 TRACK 1 26 36 4
Contributing Factors Pocket track located in tunnel Both incident trains 8-car consists 6/20/2012 Incident o Train Operator transferred to Red Line on June 17, 2012 (new pick) 6/27/2012 Incident o Train Operator recent graduate on May 4, 2012 5
Actions Taken by Management Re-issued Permanent Order T-12-09 on July 2, 2012 Metrorail Safety Rules and Procedures Revision i to Rule 3.67 - operator cannot pass red signals unless authorized by Operations Control Center (OCC) o Operator must sign acknowledgement Terminal Supervisor communication to Operator prior to entering pocket track Increase quality control checks Reiterated rules at Local Safety Committee meetings Published rule reminder in newsletter 6
Process Improvements Engineers analyzing installation of interlocking panel in Grosvenor block house 7
Washington Metropolitan Area Transit Authority Friction Ring Incident June 28, 2012 Safety and Security Committee July 12, 2012
Investigation Overview Friction ring discovered on wayside June 28, 2012 near Minnesota Avenue 2
Review of Incident Investigation Some evidence of undertorque on bolts Inconsistent safety wire installation (Mil standard and manufacturer standard) Evidence of wet torque and dry torque on bolts Bolts with safety wiring holes burred Some Bellville washers (lock washers) flat Process of installation across multiple shop locations 3
Friction Rings 2/3K & 4K 5K/6K 4
Process Improvement Define short term inspection procedures Develop consistent installation processes Train technicians on installation Further develop quality control inspections 5
Washington Metropolitan Area Transit Authority Evacuation Incident Train No. 502 College Park Station July 3, 2012 Safety and Security Committee July 12, 2012
Timeline: July 3, 2012 549PMT 5:49 PM-Train 502 reports brakes in emergency 6:07 PM-Train 502 reports unable to recharge consist 6:09 PM-Train 503 passengers offloaded to prepare for recovery 6:14 PM-Train 503 reports unable to move beyond 514+00 2
Timeline: July 3, 2012 (cont d) Train Operator 502 announces to passengers s rescue train unable to effect recovery 6:15 PM-Metro Transit Police Department (MTPD) arrived at station 6:23 PM-Passengers begin to self-evacuate MTPD estimates approximately 200 passengers o MTPD on-site and effect Emergency Trip Stations to de-energize third rail on all tracks 6:46 PM-MTPD completes managed evacuations of remaining passengers approximately 120 3
Diagram of Incident 4
Cause Momentary loss of Potomac Electric Power Company (PEPCO) main feeders to Traction Power Sub-Station Station (TPSS) results in loss of third rail power 5
Factors Contributing to Communication Issues Remote Terminal Unit (RTU) in failure from June 30 th (due to storm) unable to determine third rail power energization in Operations Control Center (OCC) Radio system issues o Off-site tower transmission problems, loss of utility feed 6
Process Improvement Standard operations protocol for: o o calling local Fire Department during disabled train incident evacuating train after predetermined timeframe Improved communications with customers at site locations Education of passengers on hazards of evacuating to roadway without supervision (third rail power, other train moves) 7
Washington Metropolitan Area Transit Authority Derailment Incident Train No. 507 West Hyattsville July 6, 2012 Safety and Security Committee July 12, 2012
Timeline: July 6, 2012 4:41 PM-Third rail power down 4:47 PM-Operation Control Center (OCC) notified Train 507 was derailed 4:48 PM-OCC notifies Fire Department (Bladensburg first to respond) and Metro Transit Police Department (MTPD) 5:12 PM-MTPD develops plan for managed evacuation with Fire Department 2
Timeline: July 6, 2012 (cont d) 5:24 PM MTPD begins managed evacuation 5:40 PM-MTPD completes managed evacuation 7:44 PM-Recovery efforts begin July 9, 2012 2:25 AM-Track returned to service 3
Incident Scene Backend of train after re-railed 4
Incident Scene Heat Kink 5
Diagram of Incident Damaged Track Area Approximately 1300 FT 6
Investigation Probable Cause o Heat kink due to extreme temperatures Maintenance History o Last walking inspections-thursday July 5, 2012 o Heat ride inspections were being conducted d throughout h t the day 7
Process Improvement De-stressing crews currently engaged g during rail laying and flash butt welding Revised preferred laying temperature standards in June 2011 o Prior to June 2011: 85 +5 /- 10 o New standard: 95 +/- 10 8
Process Improvement (cont d) Reassessment of standard protocol concerning excessive temperatures o o o o o Heat rides Speed reductions Re-assess other existing standards, i.e. ballast on shoulder Remote monitoring (prototype) Continuous process improvement for passenger communication 9