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NTSB SAFETY RECOMMENDATION
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National Transportation Safety Board
Washington, DC 20594
August 11, 2010
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NTSB Safety Recommendations R-10-8 through -22
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The National Transportation Safety Board makes the following
safety recommendations to the Washington Metropolitan Area
Transit Authority:
Because of the susceptibility to pulse-type parasitic
oscillation that can cause a loss of train detection by the
Generation 2 General Railway Signal Company audio frequency
track circuit modules, establish a program to permanently
remove from service all of these modules within the
Metrorail system. (R-10-8)
Establish periodic inspection and maintenance procedures to
examine all audio frequency track circuit modules within the
Metrorail system to identify and remove from service any
modules that exhibit pulse-type parasitic oscillation. (R-
10-9)
Review the process by which Metrorail technical bulletins
and other safety information are provided to employees and
revise that process as necessary to ensure that (1)
employees have received the information intended for them,
(2) employees understand the actions to be taken in response
to the information, and (3) employees take the appropriate
actions. (R-10-10)
Completely remove the unnecessary Metrorail wayside
maintenance communication system to eliminate its potential
for interfering with the proper functioning of the train
control system. (R-10-11)
Conduct a comprehensive safety analysis of the Metrorail
automatic train control system to evaluate all foreseeable
failures of this system that could result in a loss of train
separation, and work with your train control equipment
manufacturers to address in that analysis all potential
failure modes that could cause a loss of train detection,
including parasitic oscillation, cable faults and placement,
and corrugated rail. (R-10-12)
Based on the findings of the safety analysis recommended in
R-10-12 incorporate the design, operational, and maintenance
controls necessary to address potential failures in the
automatic train control system. (R-10-13)
Implement cable insulation resistance testing as part of
Metrorail's periodic maintenance program. (R-10-14)
Work with the Tri-State Oversight Committee to
satisfactorily address the recommendations contained in the
Federal Transit Administration's March 4, 2010, final report
of its audit of the Tri-State Oversight Committee and the
Washington Metropolitan Area Transit Authority. (R-10-15)
Require that your safety department; representatives of the
operations, maintenance, and engineering departments; and
representatives of labor organizations regularly review
recorded operational data from Metrorail train onboard
recorders and the Advanced Information Management system to
identify safety issues and trends and share the results
across all divisions of your organization. (R-10-16)
Develop and implement a non-punitive safety reporting
program to collect reports from employees in all divisions
within your organization, and ensure that the safety
department; representatives of the operations, maintenance,
and engineering departments; and representatives of labor
organizations regularly review these reports and share the
results of those reviews across all divisions of your
organization. (R-10-17)
Review the Hazard Identification and Resolution Matrix
process in your system safety program plan to ensure that
safety-critical systems such as the automatic train control
system and its subsystem components are assigned appropriate
levels of risk in light of the issues identified in this
accident. (R-10-18)
Develop a formal process by which the general manager and
managers responsible for Washington Metropolitan Area
Transit Authority operations, maintenance, and engineering
will periodically review, in collaboration with the chief
safety officer, all safety audits and open corrective action
plans, and modify policy, identify and commit resources, and
initiate any other action necessary to ensure that the plans
are adequately addressed and closed within the required time
frame. (R-10-19)
Remove all 1000-series railcars as soon as possible and
replace them with cars that have crashworthiness collision
protection at least comparable to the 6000-series railcars.
(R-10-20)
Ensure that the lead married-pair car set of each train is
equipped with an operating onboard event recorder. (R-10-21)
Develop and implement a program to monitor the performance
of onboard event recorders and ensure they are functioning
properly. (R-10-22)
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http://www.ntsb.gov/recs/letters/2010/R-10-008-022.pdf
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The complete recommendation letter is available on the Web
at the URL indicated above.
The letter is in the Portable Document Format (PDF) and can
be read using the Acrobat Reader 5.0 or later from Adobe
(http://www.adobe.com/prodindex/acrobat/readstep.html (http://www.adobe.com/prodindex/acrobat/readstep.html)).
An archive of recommendation letters is available at
http://www.ntsb.gov/recs/letters/letters.htm (http://www.ntsb.gov/recs/letters/letters.htm).
Electronic versions of letters may or may not include
enclosures; however, related publications, accident
briefs, and aviation accident synopses may be found
on the NTSB website.
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