Mike Johnson FDOT MTAP Austin, TX November 2007

1. State Safety & Security Oversight (SSO)ofRail Fixed Guideway Transit Systems“Are States”Answerable and Accountable? Mike Johnson FDOT MTAP Austin, TX November 2007

2. 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

3. 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.

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

5. 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. 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. Event Description

6. 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.

7. Initial Response Actions • 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 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.

8. 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. Injuries and Property Damage

9. 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.

10. 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.

11. 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.

12. NTSB Finding of Probable Cause • NTSB Public Hearing on September 11, 2007: • “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.

13. 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.”

14. NTSB Contributing Factors • 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.

15. NTSB Position…… • 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: • “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.”

16. NTSB Depiction of SSO Program

17. Extended Accountability to the SSO Agency and FTA • 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.

18. 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.

19. 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.

20. 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.

21. 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.

22. NTSB Recommendations (cont’d) • 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.

23. NTSB Recommendations (cont’d) • To the State of Illinois: • 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: • 6. Determine if track safety deficiencies on the Chicago Transit Authority’s 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.

24. NTSB Recommendations (cont’d) • 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.

25. NTSB Recommendations (cont’d) • 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 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.

26. NTSB Recommendations (cont’d) • 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.

27. 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.

28. 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