Miami, Florida
November 28, 2008
NTSB Number: RAR-11-01
NTIS Number: PB2011-916301
Adopted November 8, 2011
PDF
About 4:44 p.m., eastern standard time, on November 28, 2008, a three-car train operating along a fixed guideway (defined by Title 49 Code of Federal Regulations Part 659 as any light, heavy, or rapid rail system, monorail, inclined plane, funicular, trolley, or automated guideway) on E Concourse at Miami International Airport near Miami, Florida, failed to stop at the passenger platform and struck a wall at the end of the guideway. Although a maintenance technician was monitoring train operations from the lead car of the train when the accident occurred, the train was operating in fully automatic mode without a human operator. The maintenance technician and five passengers on board the train were injured in the accident. One person on the passenger platform also required medical attention.
The National Transportation Safety Board determines that the probable cause of this accident was the installation by Johnson Controls, Inc., maintenance technicians of a jumper wire that prevented the overspeed/overshoot system from activating to stop the train when the crystal within the primary program stop module failed. Contributing to the accident were (1) the failure of Johnson Controls, Inc., to provide its maintenance technicians with specific procedures regarding the potential disabling of vital train control systems during passenger operations, (2) ineffective safety oversight by the Miami-Dade Aviation Department, (3) lack of adequate safety oversight of such systems by the state of Florida, and (4) lack of authority by the U.S. Department of Transportation to provide adequate safety oversight of such systems.
The following safety issues were identified during this accident investigation:
As a result of this investigation, the National Transportation Safety Board makes safety recommendations to the U.S. Department of Transportation, to the 50 states and the District of Columbia, to Miami-Dade County, and to Johnson Controls, Inc. The National Transportation Safety Board also reiterates a previously issued recommendation to the U.S. Department of Transportation.
As a result of its investigation of this accident, the National Transportation Safety Board makes the following safety recommendations:
To the U.S. Department of Transportation:
Working with the 50 states and the District of Columbia, identify all fixed guideway transportation systems within each jurisdiction. (R-11-1)
To the 50 States and the District of Columbia:
Working with the U.S. Department of Transportation, identify all fixed guideway transportation systems within your jurisdiction. (R-11-2)
Obtain the statutory authority to provide safety oversight of all fixed guideway transportation systems that operate within your jurisdiction, regardless of their funding authorization or the date they began operation. (R-11-3)
To Miami-Dade County:
Develop and implement a system safety program plan to identify and manage safety hazards on all fixed guideway transportation systems within your jurisdiction. (R-11-4)
To Johnson Controls, Inc.:
Implement procedures to prohibit the deactivation of safety-critical systems on fixed guideway transportation systems in passenger service on all properties maintained by Johnson Controls, Inc. (R-11-5)
To the U.S. Department of Transportation:
Continue to seek the authority to provide safety oversight of rail fixed guideway transportation systems, including the ability to promulgate and enforce safety regulations and minimum requirements governing operations, track and equipment, and signal and train control systems. (R-10-3)
