Transcript NTSB - Chicago Transit Authority Investigation

State Safety & Security Oversight (SSO)
of
Rail Fixed Guideway Transit Systems
“Are States”
Answerable and Accountable?
Mike Johnson FDOT
MTAP Austin, TX
November 2007
49 CFR Part 659 Rail Fixed Guideway
Systems; State Safety Oversight
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Requires the state to designate a safety and security
oversight agency (SSO)
Requires the SSO to develop a program standard for
both Safety and Security
SSO must require, approve, track and monitor:
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System Safety and Security Plans and annual reviews
Internal Safety and Security Audits
Rail Transit Agency Hazard Management process
Corrective Action plans resulting from audits or investigations
Annual Reports from the Rail Transit Agency
Accident investigation procedures
Other SSO Responsibilities………
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Require Accident and Security incident notification
Investigate or cause to be all accidents/incidents
meeting notification and investigation thresholds
Conduct 3 year safety and security reviews
Prepare and submit annual reports to FTA
summarizing oversight activities for prior 12 months
Submit annual certification
Identify a process for evaluating findings resulting
from an NTSB investigation and determining
corrective actions for the transit agency.
NTSB Investigation
of
Chicago Transit Authority (CTA)
July 11, 2006 Train Derailment
Findings and Recommendations
Event Description
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On Tuesday, July 11, 2006,
shortly after 5:00 p.m., the
operator of train number 220,
an 8-car train traveling
northbound in the CTA Blue
Line subway, received a “blue
light alarm” on his control
panel, indicating a problem
with one of the cars.
– The train had operated
normally through
Clark/Lake Station and
was proceeding toward
Grand/Milwaukee station.
– The “blue light” operated
in conjunction with an
exterior indicator that
illuminated both sides of
the problem car.
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The operator stopped the
train, and looked back
through his window to
determine which car was
having problems.
He was unable to see the
external indicator light due to
track curvature and limited
visibility.
The operator decided to
address the problem at the
next station, and proceeded
forward.
As the train began to move,
its emergency-braking mode
automatically activated and
brought the train to a stop.
The last car of train number 220
had derailed in a slight curve to
the left approximately 53 feet past
Clark/Lake Station.
The point of derailment, later
identified by NTSB, was the
approximate location where the
train was when the “blue light”
warning activated.
At the point of derailment, an
electric arc caused material under
the train to catch fire. Thick
smoke began to fill the tunnel.
The front of the train was now
located approximately 350 feet
from the emergency exist grate at
Clinton and Fulton.
Initial Response Actions
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The train operator immediately
contacted CTA’s Control Center and
requested that power be removed.
The train operator then exited the
train and walked along the catwalk
to investigate.
Many passengers had selfevacuated from the rear of the train
and were walking toward him,
reporting smoke and fire.
The train operator used his voice
and hand signals to direct more than
1,000 passengers away from the
smoke to the emergency exit grate
at Clinton and Fulton.
Injuries and Property Damage
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The evacuation took a little
less than an hour.
The Chicago Fire
Department, which assisted
in the evacuation, reported
that 152 persons were
treated for injuries, mostly
related to smoke inhalation.
There were no fatalities.
Total damage to the derailed
CTA vehicle and track
exceeded $1 million.
NTSB Response
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After being notified of the accident, NTSB
immediately dispatched a 12-member investigation
team to CTA.
During the course of its on-site investigation, NTSB:
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Interviewed the train operator and reviewed his personnel
records, training records, hours of service records, and drug
and alcohol test results.
Interviewed passengers, witnesses, and emergency
responders.
Conducted an extensive examination of the derailment site.
Collected samples from damaged rail equipment, track, ties,
and fasteners, and sent them to their lab for analysis.
NTSB Response -- Continued
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NTSB also:
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Requested and reviewed CTA track inspection records for
the past 12 months.
Observed a track inspection on the territory including the
derailment area.
Conducted interviews with track walkers and maintenance
personnel, and CTA personnel knowledgeable in traction
power and ventilation systems.
Tested the signal system and reviewed signal data.
Regional Transportation Authority (RTA) is the Illinois
State Safety Oversight Agency (SSO)
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NTSB made the SSO (RTA) a party to the investigation and
conducted interviews with the RTA personnel.
NTSB and FTA
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Unlike CTA and Illinois RTA, FTA was not a party to the
investigation.
However, NTSB conducted a meeting with FTA on November 28,
2006 regarding the CTA derailment.
NTSB also made a series of requests from FTA regarding:
– Existing industry track inspection standards and
procedures,
– Part 659 requirements related to maintenance,
– Existing approaches used in the rail transit industry for
training rail maintenance personnel,
– Existing qualifications of rail transit track inspectors and
supervisors, and
– Qualifications of rail transit safety personnel and SSO
personnel to perform track inspections.
NTSB Finding of Probable Cause
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NTSB Public Hearing on September 11, 2007:
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“The Chicago Transit Authority’s ineffective management
and oversight of its track inspection and maintenance
program and its system safety program resulted in unsafe
track conditions.”
……… For the first time, NTSB cited the system safety
program managed by a rail transit agency part of the
probable cause of an accident it investigated.
NTSB Conclusions
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“The dark area on the inner rail of the curve, the
abrasion on the tie plates and ties, the broken lag
screws, and the tie plates’ elongated fastener holes in
the area of the derailment were all readily observable
and should have been documented during walking
inspections.”
“Because the Chicago Transit Authority failed to
establish an effective track inspection and
maintenance program, unsafe track conditions and
deficiencies were not corrected.”
NTSB Contributing Factors
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Contributing to the accident were:
– The SSO agency (RTA’s) failure to require that
action be taken by the Chicago Transit Authority
to correct unsafe track conditions, and
– The Federal Transit Administration’s ineffective
oversight of the SSO agency (RTA).
Contributing to the seriousness of the accident was:
– Smoke in the tunnel and the delay in removing
that smoke.
NTSB Position……
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CTA’s System Safety Department and the
SSO (Illinois RTA) had ample opportunity prior to the
derailment to identify the deteriorating track
conditions and require corrective action.
FTA also had ample opportunity to ensure that the
SSO (Illinois RTA) identified these conditions and
required corrective action.
Final NTSB discourse:
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“Through implementation of Part 659, CTA’s
System Safety Department, Illinois RTA, and FTA
had an obligation to identify these conditions and
appropriate authority to require corrective
actions, but failed to do so.”
NTSB Depiction of SSO Program
Safety Oversight
Extended Accountability
to the SSO Agency and FTA
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By asserting that CTA’s System Safety Department
had responsibility for independent oversight of CTA’s
track inspection and maintenance, NTSB also
asserted that the SSO (Illinois RTA) had responsibility
to oversee CTA’s System Safety Department in
carrying out this responsibility.
By extension, FTA also had responsibility to oversee
the SSO (Illinois RTA) in carrying out its oversight of
CTA’s System Safety Department.
Failed Role of Oversight
NTSB classified this accident as a
failure of safety oversight at all
levels rather than a failure of local
government to adequately fund needed
maintenance repairs and a failure of
rail transit agency management to
ensure QA/QC in track inspection and
maintenance.
Limitations on FTA Authority
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NTSB stated that FTA has the "power of the purse" in
requiring the implementation of corrective actions and in
conferring this authority to State agencies.
FTA is expressly prohibited by Congress from regulating
the operations of rail transit systems (49 U.S.C. 5334 (b) (1))
At the current time, FTA does not have the authority, nor
can it confer such authority to the States in the SSO
program, to:
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Establish and enforce track safety standards,
Set training requirements and certifications for track
inspectors and supervisors,
Require the rail transit agency safety function to oversee the
performance of track inspection and maintenance,
Require a specific quality assurance/quality control (QA/QC)
process for overseeing track inspection and maintenance,
Require immediate implementation of corrective actions to
address track deficiencies, or
Impose civil and criminal penalties on public transportation
agencies for failure to immediately correct track deficiencies.
Authority to Require Corrective Action
At the current time, FTA regulation 49 CFR
Part 659 provides States with the authority to
require rail transit agencies to implement
corrective actions for:
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Findings that the SSPP is not being
implemented,
Findings that the SSPP needs to be updated,
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Findings from accident and hazard
investigations.
Total of 14 NTSB Recommendations
4 – Federal Transit Administration
1 - State of Illinois
2 – SSO (Regional Transportation Authority)
1 – Chicago Transit Board
6 – Chicago Transit Authority
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To the Federal Transit Administration:
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1. Modify your program to ensure that State safety oversight
agencies take action to prompt rail transit agencies to correct all
safety deficiencies that are identified as a result of oversight
inspections and safety reviews, regardless of whether those
deficiencies are labeled as “findings,” “observations,” or some
other term.
2. Develop and implement an action plan, including provisions for
technical and financial resources as necessary, to enhance the
effectiveness of State safety oversight programs to identify safety
deficiencies and to ensure that those deficiencies are corrected.
NTSB Recommendations (cont’d)
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To the Federal Transit Administration:
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3. Schedule the Chicago Transit Authority as a priority for
receiving the maintenance oversight workshop and the training
course to be developed for track inspectors and supervisors that
will address the unique demands of track inspection in the rail
transit environment.
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4. Inform all rail transit agencies about the circumstances of the
July 11, 2006, Chicago Transit Authority subway accident and
urge them to examine and improve, as necessary, their ability to
communicate with passengers and perform emergency
evacuations from their tunnel systems, including the ability to (1)
identify the exact location of a train, (2) locate a specific call box,
and (3) remove smoke from their tunnel systems.
NTSB Recommendations (cont’d)
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To the State of Illinois:
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5. Evaluate the Regional Transportation Authority’s effectiveness,
procedures, and authority, and take action to ensure that all safety
deficiencies identified during rail transit safety inspections and
reviews of the Chicago Transit Authority are corrected, regardless of
whether those deficiencies are labeled as “findings,” “observations,”
or some other term.
To the Regional Transportation Authority:
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6. Determine if track safety deficiencies on the Chicago Transit
Authority’s Dearborn Subway in the area of the derailment have
been adequately repaired.
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7. Strengthen your follow-up action on Chicago Transit Authority
system safety reviews to ensure that the Chicago Transit Authority
corrects all identified safety deficiencies, regardless of whether
those deficiencies are labeled as “findings,” “observations,” or some
other term.
NTSB Recommendations (cont’d)
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To the Chicago Transit Board:
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8. Direct the Chicago Transit Authority to correct all
safety deficiencies identified by the Regional
Transportation Authority in its most recent and future
safety inspections and reviews, regardless of whether
those deficiencies are labeled as “findings,”
“observations,” or some other term.
NTSB Recommendations (cont’d)
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To the Chicago Transit Authority:
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9. Correct all safety deficiencies identified by the Regional
Transportation Authority in its most recent and future safety
inspections and reviews, regardless of whether those
deficiencies are labeled as “findings,” “observations,” or
some other term.
10. Examine all of the elements in the American Public
Transportation Association’s “Standard for Rail Transit Track
Inspection and Maintenance” and incorporate all appropriate
elements of this standard in your system safety program.
Specifically, include the regular use of track geometry vehicle
inspections and the inspection of rail for internal defects in
your system safety program.
11. Evaluate all territories to determine the number of
inspectors and the amount of time needed to ensure that
adequate track inspections are conducted, and implement
appropriate changes.
NTSB Recommendations (cont’d)
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To the Chicago Transit Authority:
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12. Schedule as a priority the maintenance oversight
workshop and the training course that the Federal Transit
Administration plans to develop for track inspectors and
supervisors that will address the unique demands of track
inspection in the rail transit environment.
13. Perform a comprehensive computational study of the
existing ventilation system using various fire and smoke
scenarios to identify potential deficiencies, and make
improvements to the ventilation system and smoke removal
procedures based on the findings of the study. These actions
should address reinstalling fan 108 and replacing
unidirectional fans (including fan 133) with dual direction fans
as needed.
14. Examine and improve as necessary your ability to
communicate with passengers and perform emergency
evacuations.
Implications for the State
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Any NTSB investigation of a rail transit agency accident also includes an
investigation of the state oversight agency (SSO).
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The SSO agency can and will be identified in the report findings as a
contributing factor to the accident.
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The NTSB can also identify in their report “conclusions of the investigation”
the SSO agency as a causal factor or "probable cause" of the accident
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NTSB can and will issue recommendations to all identified contributors to the
accident, including the SSO agency, the state as a whole, and governing
boards.
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NTSB Report submits their report to Congress and tracks compliance with
the recommendations, therefore any recommendations issued to the state
must be addressed.
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NTSB determined that the resources Illinois RTA devoted to its SSO
program were highly inadequate. Illinois SSO (RTA) provides .5 fulltime equivalents per year plus contractor support.
Important Lessons Drawn
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Part 659 is an unfunded FTA mandate, but extremely important that states
give this regulation the utmost attention .
The NTSB report indicated that through implementation of Part 659, the
SSO agency, in addition to the Transit Agency and FTA, had an obligation
to identify deficient and unsafe conditions and appropriate authority to
require corrective actions, but failed to do so.
States should evaluate resources, staffing and training programs, to
ensure an effective and responsible oversight program for the rail fixed
guideway systems can be administered.
It could happen in your state or my state, just like it did in Illinois, and none
of us want to be in a position of being interviewed by NTSB, being part of
an investigation, or named as a causal or contributing factor to an
accident.
So, What is your Answer to the Question..............................
”Are we, the states……… Answerable and Accountable”?
Thank You…...Questions