State Safety

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State Safety Security Oversight (SSO)ofRail
Fixed Guideway Transit SystemsAre
StatesAnswerable and Accountable?

• Mike Johnson FDOT
• MTAP Austin, TX
• November 2007

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49 CFR Part 659 Rail Fixed Guideway Systems
State Safety Oversight

• 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
• 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

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Other SSO Responsibilities

• 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.

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• NTSB Investigation
• of
• Chicago Transit Authority (CTA)July 11, 2006
  Train Derailment
• Findings and Recommendations

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Event Description

• On Tuesday, July 11, 2006, shortly after 500
  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.

• 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.

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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.
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Initial Response Actions

• The train operator immediately contacted CTAs
  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 self-evacuated 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.

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Injuries and Property Damage

• 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.

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NTSB Response

• 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
• 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.

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NTSB Response -- Continued

• NTSB also
• 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)
• NTSB made the SSO (RTA) a party to the
  investigation and conducted interviews with the
  RTA personnel.

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NTSB and FTA

• 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.

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NTSB Finding of Probable Cause

• NTSB Public Hearing on September 11, 2007
• The Chicago Transit Authoritys 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.

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NTSB Conclusions

• 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.

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NTSB Contributing Factors

• Contributing to the accident were
• The SSO agency (RTAs) failure to require that
  action be taken by the Chicago Transit Authority
  to correct unsafe track conditions, and
• The Federal Transit Administrations 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.

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NTSB Position

• CTAs 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
• Through implementation of Part 659, CTAs
  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.

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NTSB Depiction of SSO Program
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Extended Accountability to the SSO Agency and FTA

• By asserting that CTAs System Safety Department
  had responsibility for independent oversight of
  CTAs track inspection and maintenance, NTSB also
  asserted that the SSO (Illinois RTA) had
  responsibility to oversee CTAs 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 CTAs System Safety Department.

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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.

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Limitations on FTA Authority

• 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
• 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.

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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
• Findings that the SSPP is not being implemented,
• Findings that the SSPP needs to be updated, and
• Findings from accident and hazard investigations.

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Total of 14 NTSB Recommendations4 Federal
Transit Administration1 - State of Illinois2
SSO (Regional Transportation Authority)1
Chicago Transit Board6 Chicago Transit
Authority

• To the Federal Transit Administration
• 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.

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NTSB Recommendations (contd)

• To the Federal Transit Administration
• 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.
• 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.

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NTSB Recommendations (contd)

• To the State of Illinois
• 5. Evaluate the Regional Transportation
  Authoritys 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
• 6. Determine if track safety deficiencies on the
  Chicago Transit Authoritys Dearborn Subway in
  the area of the derailment have been adequately
  repaired.
• 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.

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NTSB Recommendations (contd)

• To the Chicago Transit Board
• 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.

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NTSB Recommendations (contd)

• To the Chicago Transit Authority
• 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 Associations 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.

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NTSB Recommendations (contd)

• To the Chicago Transit Authority
• 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.

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Implications for the State

• Any NTSB investigation of a rail transit agency
  accident also includes an investigation of the
  state oversight agency (SSO).
• The SSO agency can and will be identified in the
  report findings as a contributing factor to the
  accident.
• 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
• 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.
• NTSB Report submits their report to Congress and
  tracks compliance with the recommendations,
  therefore any recommendations issued to the state
  must be addressed.
• NTSB determined that the resources Illinois RTA
  devoted to its SSO program were highly
  inadequate. Illinois SSO (RTA) provides .5
  full-time equivalents per year plus contractor
  support.

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Important Lessons Drawn

• 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