NTSB Press Release

FOR IMMEDIATE RELEASE: March 23, 2006 SB-06-15

NTSB DETERMINES THAT THE OPERATOR'S FAILURE TO APPLY BRAKES CAUSED WASHINGTON SUBWAY COLLISION IN 2004

Washington, DC -- The National Transportation Safety Board determined today the probable cause of a collision between two Washington Metropolitan Area Transit Authority trains at the Woodley Park Zoo/Adams Morgan Station was the failure of the operator of a non-revenue train to apply the brakes to stop his train likely due to his reduced alertness. Contributing to the accident was the lack of a rollback protection feature to stop the train, when operated in the manual mode.

"Implementation of the Safety Board's recommendations on roll back protection and adequate time off between shifts for train operators will enhance safety for thousands of persons who use these trains daily," said NTSB Acting Chairman Mark Rosenker.

On November 3, 2004 train 105, was in the process of discharging and loading passengers when it was struck by non-revenue train 703, which was traveling approximately 35 mph after rolling backwards for more than 2,200 feet. There were no fatalities. About 20 passengers went to the hospital and property damage was estimated at $3 million.

On November 7, 2004, WMATA issued a memorandum to all train operators and Metrorail supervisors concerning the absence of a rollback protection feature on the Rohr 1000-series cars when operated in the manual mode. Two days later, WMATA issued a supplement to its previous memorandum extending the reminder to cover the entire fleet of Rohr cars.

On November 22, 2004, the Safety Board issued an urgent safety recommendation to WMATA to immediately revise the directions to train operators contained in those two post-accident memorandums to include specific written instructions for identifying and responding to emergency rollback situations, and provide training to operators on the procedures to follow if such a rollback event occurs.

WMATA responded to the Safety Board's urgent recommendation on November 23, 2004, issuing new bulletins again reminding operators that in the manual mode there is no rollback protection except in the rehabilitated Breda cars. WMATA also advised operators to take the following actions in the event of a rollback: in manual mode, a rollback is stopped by application of the train brakes; should a rollback of greater than five seconds occur, the operator shall apply maximum service brakes by pulling the brake handle to the B4 position; and should the train not stop within another four seconds, the operator shall apply the emergency brakes by releasing the safety handle or by depressing the emergency stop button.

On May 31, 2005, pending instructions to include the discussion of speed in the written instructions for identifying and responding to a rollback situation, the Safety Board classified the urgent recommendation "Open-Acceptable Response."

In a letter dated February 15, 2006, to the Safety Board, WMATA declined to include written instructions to operators suggested by the Board.

The Safety Board simulation testing found that trains that did not have the rollback protection feature could not be controlled by applying power by the operator when the train speed exceeded 2 mph in a rollback situation. In today's Board meeting, the Safety Board reclassified that urgent safety recommendation from open-acceptable response to open-unacceptable response.

During the Safety Board's investigation, it noted that the train operator's inadequate sleep may have contributed to his failure to respond to the train's 78-second rollback and prevent the accident by applying the brakes.

As a result of its investigation, the Safety Board made the following recommendations

To the Washington Metropolitan Area Transit Authority:

Equip, as soon as possible, all existing and future trains with rollback protection for trains operated in the manual mode.
Either accelerate retirement of Rohr-built railcars, or, if those railcars are not retired but instead rehabilitated, then Rohr-built passenger railcars should be retrofitted with crashworthiness collision protection that is comparable to 6000-series railcars.

To the Federal Transit Authority:

Require transit agencies, through the system safety program and hazard management process if necessary, to ensure that the time off between daily tours of duty, including regular and overtime assignments, allows train operators to obtain at least eight hours of uninterrupted sleep.
Assess the adequacy of WMATA's current organizational structure and ensure that it effectively identifies and addresses safety issues.
Develop transit railcar design standards to provide adequate means for safe and rapid emergency responders entry and passenger evacuation.
Develop minimum railcar design standards to provide adequate standards to prevent telescoping of transit railcars in collisions and establish a timetable for removing equipment that can not be modified to meet the new standards.

A synopsis of the Board's report including a complete listing of conclusions and recommendations is available on the Railroad Publications page of the Board's website, www.ntsb.gov. The Board's full report will be available on the website in a few weeks.

Media Contact:
Terry N. Williams, (202) 314-6100, williat@ntsb.gov

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