Metro News Release
For immediate release: May 13, 2010
Investigation reveals no hazardous conditions
Train operator perceived possible situation, acted properly
The preliminary findings of an extensive investigation into an incident that took place on May 5, during which a Metrorail operator applied his emergency brake have determined that “at no time was a hazardous condition present,” according to Metro Chief Safety Officer James Dougherty. The investigation also found that the train operator acted properly to what he perceived was a hazardous situation.
Summary of Event
At 8:51 a.m. on May 5, Red Line train 122 departed the Forest Glen Metrorail station heading in the direction of Glenmont when the train operator observed the tail lights of the train ahead as it approached the Wheaton Metrorail station. He believed that his train was traveling too fast and so he placed the “master controller” into emergency brake mode and brought the six-car train to a stop. The emergency “mushroom” button for braking was not depressed. Train 122 stopped approximately 600 feet from the one ahead of it.
The first train had stopped temporarily prior to pulling up to the Wheaton Metrorail station platform. Once the first train ahead cleared the Wheaton Metrorail station platform, train 122 proceeded to the station. The operator exited the train and notified Metro’s Rail Operations Control Center using an emergency wayside phone to alert the controllers that he had applied the emergency brake because he felt he had been too close to the train ahead. The Control Center immediately implemented an “absolute block” between Forest Glen and Wheaton Metrorail stations. (An “absolute block” requires a train to stop and wait for permission to move forward within a designated area or “block” of track and then wait for verification that no other train is in the “block” before moving forward. It is a safety mode to ensure that trains in a given area are kept well apart.) The train then continued one more station to the end of the line (Glenmont Metrorail station) and was taken to the rail yard, where it was isolated for investigation.
Metro’s Rail Department notified the Safety Department at about 10 a.m., however because the incident was determined not to be an emergency, the Safety Department was not dispatched to investigate. After being notified the next day (May 6), the Chief Safety Officer initiated a safety investigation and notified the Tri-State Oversight Committee.
The investigation was extensive and included the following:
- Immediately after the operator of train 122 reported that he had braked his train, operators of both trains were interviewed on May 5.
- The operator of train 122 was interviewed a second time on May 6.
- The operator of the lead train was interviewed a second time on May 7.
- A vehicle inspection of train 122 was conducted. The train was taken out of service immediately and the inspection noted the following:
- No rail wheel flat spots were found on any of the wheels. (A flat spot typically results when an emergency “mushroom” brake button has been depressed.)
- Computerized playback revealed no “loss of shunt” (no loss of ability to detect trains) for either train.
- Computerized playback showed the trains were located where they were supposed to be, and they were in fact in different train circuits.
- The operator of train 122 notified the Operations Control Center of the emergency brake application when the train reached the Wheaton Metrorail station.
- An engineering inspection of the track and circuitry between Forest Glen and Wheaton Metrorail stations noted the following results:
- The track area has original track circuit components.
- There were no water leaks around the bonds, track construction or components.
- The “wee-z bond” (the main piece of track circuitry located in the center of the tracks) appeared clean and free of debris.
- The Safety Department’s inspection of the track did not indicate any anomalies.
- The rail fasteners, clips and anchors appeared to be in good shape.
- Absolute block operations on the outbound track had been instituted immediately after the incident. (The absolute block was removed last evening, May 12).
- Total elapsed time observing the event circuit showed no unusual indications in the playback mode. No anomalies were found in the track circuit.
- Extensive equipment testing was conducted on May 7 and 8:
- Testing was performed from 1 to 4:50 a.m. on May 7. A test train was utilized to verify speed readouts through the circuits along the tracks.
- A re-enactment using the same train consists (the exact cars on both trains) was conducted on May 8 with the original train operator of train 122. The test revealed the speed commands on the train worked properly.
- A post-incident human performance inspection and review noted:
- The operator has four years of service with Metro, one year as a bus operator and three years as a train operator.
- The operator’s work schedule for the two weeks prior to May 5 indicated no excessive hours worked that could contribute to fatigue.
- During the initial interview with the supervisor, a personal cell phone was not present.
- The operator was not tested for drugs and alcohol because the incident did not meet the federal or Metro requirements for such tests.
Immediate Actions Taken
- The absolute block was put in place and remained in effect until the evening of May 12 on the outbound track to allow for the test and inspection of the automatic train control components to be completed with a full report on the findings.
- The incident train was immediately taken out of service for inspection and investigation.
- Both train operators were interviewed immediately.
Preliminary Findings and Conclusions
- At no time was a hazardous condition present.
- The operator reacted properly to what he believed was a potentially hazardous situation.
- The train operator did not anticipate a stationary train ahead of him at that location.
- The facts indicate that all track circuit components functioned properly.
- There was no loss of shunt.
- This incident has no similarity to the June 22, 2009 collision.
Preliminary Recommendations to be Implemented
- A revision to train operator orders will be made to add emergency braking as a requirement for Rail Operations Control Center notification to be issued, even in manual operation.
- Bi-weekly inspections of the affected area will continue for the next 90 days and monthly afterward up to six months as a precautionary measure.
- Staff will investigate the possibility of creating an interactive train operator simulation module.
- The Safety Department will increase its notification of rail events to the Tri-State Oversight Committee.
News release issued at 2:12 pm, May 13, 2010.