Safety Action Plan

FTA developed the 2008 Rail Transit Safety Action Plan to assess the safety of the rail transit industry and the performance of FTA’s State Safety Oversight (SSO) program in providing an added degree of confidence that the minimum requirements specified in FTA’s SSO rule, 49 CFR Part 659, are being implemented. The Action Plan uses information collected by FTA from the National Transit Database (NTD) and the SSO program between Calendar Years 2003 and 2007. The 2008 Action Plan updates the version released by FTA in 2006.

Analysis in the Safety Action Plan shows that over the five-year period between January 1, 2003 and December 31, 2007:

• Compared to other modes of surface transportation, such as highway, commuter rail and freight railroads, the rail transit industry experienced far fewer fatalities and injuries.
• Rail transit ridership increased approximately 40 percent from 2.9 billion to 3.8 billion.
• There were 2,668 total accidents, which resulted in 384 fatalities and 2,277 injuries.

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• Collisions and "other" accidents were responsible for all of the 384 fatalities reported by the rail transit agencies (164 due to collisions, and 220 due to “other” accidents).
• The number and rate of track worker fatalities has increased significantly. Between 2003 and 2007, the nation’s heavy rail agencies experienced eight (8) accidents that resulted in the deaths of ten (10) wayside workers, including track inspectors, track workers, and signal technicians. Fatality and injury rates for wayside workers are now three times their historic average in the heavy rail industry.
• Light rail agencies experienced almost 9 times as many collisions as heavy rail agencies (1,702 versus 196), while heavy rail agencies experienced approximately 3 times as many “other” accidents (349 versus 116).
• Light rail agencies experienced far more derailments than heavy rail agencies (107 versus 67), but derailments at heavy rail agencies caused far more injuries (285 versus 16).

The table below presents the accident rates per 10 million passenger trips by mode

between 2003 and 2007, and includes the five-year average rates.

Based on analysis of probable cause data between 2003 and 2007, the illegal/imprudent actions of motorists continue to provide the most common cause of accidents, followed by operating rule violations/human factors issues at the rail transit agencies. Actions of pedestrians, rail transit agency equipment failures, and accidents caused by suicides and trespassers round out the top five causes of accidents.

Accidents caused by suicides and trespassers remain the most deadly in the rail transit industry, accounting for 51 percent of all rail transit fatalities between 2003 and 2007. Illegal/imprudent actions taken by motorists, pedestrians, and passengers comprise the remaining top five causes of rail transit fatalities between 2003 and 2007.

While the total number of accidents appears to be increasing, the rate of injury per accident appears to be decreasing. In particular, between 2003 and 2007, injuries from poor maintenance decreased dramatically from 167 in 2003 to just two in 2007.

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Per 10 Million Unlinked Passenger Trips

Illegal/imprudent actions by motorists, poor maintenance, operating rule violations/human factor issues at the rail transit agencies, slips and falls, and equipment failure are the most common causes of injuries.

Based on the results of the analysis performed for this 2008 Rail Transit Safety Action Plan, FTA has identified the following Top Ten Safety Action Priorities:

• Priority #1: Improve Safety of Transit Workers, Including Right-of-Way Safety and Fatigue Management
• Priority #2: Increase Resources and Training Devoted to Safety Oversight
• Priority #3: Improve Compliance with Operating and Maintenance Rules
• Priority #4: Improve Maintenance Oversight
• Priority #5:  Reduce Collisions with Other Vehicles
• Priority #6: Reduce Collisions with Pedestrians and Trespassers
• Priority #7: Reduce Unsafe Acts by Passengers in Transit Stations
• Priority #8: Improve Integrity, Collection and Analysis of Safety Data
• Priority #9:    Improve Emergency Management and Coordination Capabilities
• Priority #10: Improve Quality of Internal Safety Audits

Over the next year, FTA’s Office of Safety and Security will be managing several different initiatives to support these Top Ten Safety Action Priorities, including the following:

• Continued outreach with the Governors of the States and the Executive Directors of the SSO agencies to promote resources for rail transit safety oversight programs.
• Continuation of FTA’s SSO Program Managers Training Curriculum, to ensure that all SSO Program Managers receive certificates from the Transportation Safety Institute (TSI) and the World Safety Organization (WSO) by the end of 2010.
• Maintenance Oversight Workshops at several rail transit agencies to galvanize attention on key maintenance issues with safety implications and to enhance their management.
• Wayside Worker Protection Guidelines, Orientation Video, and Pocket Guide to provide technical assistance for the industry.
• Track Inspection Refresher Training Course, Guidelines and Pocket Guide to provide technical assistance for the industry.

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Unlinked Passenger Trips

• Continued support for the American Public Transportation Association (APTA) Rail Transit Standards Program, including development of new standards for hours of service, wayside worker protection, and rail transit vehicle crashworthiness and emergency features.
• Continued partnership with FTA’s Office of Research, Demonstration and Innovation (TRI) to conduct research aimed at enhancing the rail transit industry's safety culture, reducing the number of suicides in the rail transit industry, and improving the design of light rail vehicles to reduce the consequences of crashes for motor vehicle occupants and pedestrians and trespassers.
• Continued partnership with Operation Lifesaver to expand public outreach regarding pedestrian and motor vehicle interface with light rail systems.
• Expansion of Transit Watch program to address safety issues stemming from reckless or inappropriate behavior in stations that leads to accidents.

• Continued partnership with the FTA Regional Offices and Project Management Oversight Consultants (PMOCs) to address safety issues in the design of New Starts and modernization/rehabilitation projects.
• Continued partnership with FTA’s Office of Budget and Policy (TBP) and the SSO agencies regarding the collection and analysis of safety data.
• Completion of three-year SSO Audit Program Cycle, including increased focus on needed resources, internal safety audit process, hazard management process, and safety data acquisition and analysis.
• Sponsorship of Annual SSO Program Meetings for SSO Program Managers and the rail transit industry to provide training, discussion, and analysis regarding the implementation of 49 CFR Part 659 requirements.

NTSB Recommendations

FTA Response Activities

Over the past two years, the National Transportation Safety Board (NTSB) has held four major hearings regarding heavy rail transit accidents at the Washington Metropolitan Area Transit Authority (WMATA) and the Chicago Transit Authority (CTA), including:

• January 23, 2008 hearing of the WMATA Dupont Circle and Eisenhower Avenue Station wayside worker fatalities.
• October 16, 2007 hearing of the WMATA derailment near the Mt. Vernon Square Station.
• September 11, 2007 hearing of the CTA derailment and evacuation between Clark/Lake and Grand/Milwaukee Stations.
• March 23, 2006 hearing of the WMATA collision between two trains at the Woodley Park-Zoo/Adams Morgan Station.

In addition, NTSB has also reviewed, but not investigated, several other accidents including a June 5, 2007 San Francisco Bay Area Rapid Transit District (BART) incident involving smoke in a tunnel that resulted in the evacuation of a train; two separate New York City Transit (NYCT) track worker fatalities in April 2007; and the January 27, 2005 fatality of a Massachusetts Bay Transportation Authority (MBTA) signal engineer. As a result of these accidents, NTSB has issued nine recommendations to the FTA aimed at strengthening the SSO Program and rail transit safety throughout the nation.

Recommendation R-06-03: FTA should ensure that agencies provide train operators eight hours of uninterrupted rest between shifts.

In response, FTA is currently working with the American Public Transportation Association’s (APTA) Operating Practices Committee to develop a standard to provide guidance limiting the hours of service of rail transit operators. It is anticipated that the standard will recommend a minimum of 10 hours off duty between shifts to allow rail transit operators to obtain 8 hours of uninterrupted rest. FTA anticipates that this standard will also contain other practices to be implemented to support an effective fatigue management program, including approaches to work scheduling and extra board management, employee pre‐employment screening, fitness‐for‐duty checks, ongoing dialogue with employees regarding their sleep habits, and managing employees with diagnosed sleep disorders.

In partnership with the Transportation Safety Institute (TSI) and the National Transit Institute (NTI), FTA is providing training to SSO agencies and rail transit agencies that emphasize techniques for assessing fatigue as a probable cause or contributing factor in rail transit accidents. TSI has begun revising its Advanced Rail Incident Investigation course to include an in‐depth module on investigating fatigue as a probable cause or contributing factor in rail transit accidents.

Additionally, FTA is considering how to strengthen its SSO Program to address NTSB’s recommendation.

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Recommendation R-06-04: FTA should ensure WMATA is identifying and resolving safety concerns.

In response, FTA has met with WMATA and Tri‐State Oversight Committee (TOC) representatives to discuss current and outstanding safety issues. FTA also performed two SSO audits of TOC, one in 2005 and one in 2007, and is aggressively tracking the resolution of audit findings.

Since the 2007 SSO audit, WMATA has hired a new General Manager and Deputy General Manager. The new WMATA leadership has demonstrated a commitment to safety within the organization by conducting Executive Safety Committee meetings and working with TOC to institutionalize the WMATA safety committee structure by revising the WMATA SSPP to include the various safety committees.

Recommendation R-06-05: FTA should require emergency access/egress standards for rail vehicles.

Through partnership with the APTA , FTA is now sponsoring development of a Rail Transit Standard entitled "Emergency Features for Rail Transit Cars." The APTA Rail Transit Standards Vehicle Inspection and Maintenance Committee is developing this document. The project will develop a consensus-based standard to recommend emergency features for inclusion on light and heavy rail transit vehicles. In light of the July 11, 2006 CTA derailment, this standard may also address additional vehicle features to support evacuation under "smoke in tunnel" conditions, such as the capability to make automated announcements from the Operations

Control Center directly to train operators and passengers on board trains. FTA and APTA conducted the first meeting for this standard in September 2007.

Recommendation R-06-06: FTA should require crashworthiness standards for rail transit vehicles that address telescoping.

FTA is currently working with APTA and the American Society of Mechanical Engineers (ASME) to develop crash energy management (CEM) standards for light and heavy rail vehicles. FTA, through its Office of Research, Demonstration and Innovation (TRI), is also undertaking an ambitious new project to research and develop CEM specifications for overhauling the front ends of existing light rail vehicles, both to improve passenger occupant survival in rail cars and to reduce the effects of an automobile collision with light rail cars. The research will investigate the use of CEM structures and applications to minimize the consequences of collisions. A final report is expected in 2009.

Recommendation R-07-10: FTA should develop an Action Plan to provide additional authority and resources to SSO agencies.

In response, FTA issued letters to each of the State Governors and SSO Executive Directors requesting additional support for the SSO Program. FTA is also developing recommended guidance for SSO agencies performing three‐year safety reviews, and will be issuing a clarification letter on the same topic, as well as a clarification letter pertaining to the Hazard Management Process requirements   of  Part  659.    FTA   is   also

sponsoring TSI Safety Auditor Training for SSO Program Managers and will be increasing its focus on corrective action plan management in the SSO audit program.

FTA intends to continue its annual SSO Program Manager Workshops and training curriculum programs.

Recommendation R-07-11: FTA should make CTA a priority in FTA’s track inspection training program.

FTA is in the process of developing a refresher Track Inspection Program, to be piloted at CTA and three other heavy rail transit agencies. In addition, FTA is developing pocket guides, refresher training courses, and a track worker protection refresher training video for distribution to the entire rail transit industry. On July 23‐24, 2008, FTA held its first ever CEO Safety Summit, in which it invited CEOs and GMs to participate in the day‐and‐a‐half meeting to help identify challenges, needs, and opportunities for improving track worker safety.

Recommendation R-07-12: FTA should publicize the challenges encountered with tunnel evacuations and the best practices for subway evacuation.

In response, FTA emailed the NTSB report pertaining to the June 2007 BART tunnel evacuation to the full SSO community. During the recent Safety and Security Roundtable held in New York City, FTA also held a special session   on  managing  evacuations  under

“smoke in tunnel” conditions. FTA is also working with APTA to develop a rail transit standard for emergency evacuations in the rail transit environment.

Recommendation R-02-19: FTA should require event data recorders on all rail vehicles purchased or rehabilitated with Federal monies.

FTA has taken a number of steps to address these recommendations and is meeting with NTSB to discuss FTA’s statutory authority and ability to issue such a requirement. In preparation for this meeting, FTA has developed a legal brief explaining FTA’s current level of statutory authority. In addition, FTA is conducting annual surveys and monitoring of the industry and is developing technical assistance guidelines on procuring event recorders. FTA will be issuing a “Dear Colleague” letter to each of the heavy and light rail transit agency General Managers explaining NTSB’s recommendation and soliciting their support in meeting the recommendations. FTA will also be working with its regional offices and its PMOCs through the Office of Engineering to provide additional oversight of the industry.

FTA has made significant progress to address NTSB’s recommendations. However, much more is still required. FTA is encouraged by the support it has received from the rail transit industry and looks forward to working with its industry partners including rail transit agencies and SSO agencies, over the coming year to make even greater strides in improving the safety of the nation’s rail transit industry.

3rd Annual SSO Program Managers Workshop

Charlotte, North Carolina

On April 14 – 17, FTA held its 3rd Annual SSO Program Managers Workshop in Charlotte, North Carolina. The North Carolina Department of Transportation and the Charlotte Area Transit System (CATS) hosted the three‐and‐a‐half day meeting. Mr. James Dougherty, the CATS General Manager for Safety and Security, led a tour of the Operations Control Center and Vehicle Maintenance Facility for the recently opened CATS LYNX light rail system.

The meeting included discussions on a wide range of issues currently faced by the rail transit industry. Topics included FTA’s current SSO Program initiatives and activities, an update of FTA’s response to recent National Transportation Safety Board (NTSB) accident investigation findings and recommendations, current SSO audit program activities and concerns, the status of the SSO Program Managers Training Curriculum, and the 2008 Rail Safety Action Plan.

Participants also discussed and recommended methods for performing SSO Three‐Year Reviews. Facilitators distributed FTA’s Draft Recommended Practice for States Conducting Three‐Year Safety Reviews. Three‐Year Review workshop sessions focused on key processes for conducting document reviews, records reviews, interviews, field observations, and inspections and measurements, as well as recommendations for generating and tracking review findings. FTA presented  techniques  that  can  be  used  to

strengthen and broaden the depth of SSO Three‐Year Reviews. Participants reviewed and discussed the strengths and weaknesses of each technique and offered FTA comments and suggested revisions to the draft Three‐Year Review guidance.

The meeting also addressed FTA’s Wayside Worker Protection and Maintenance Oversight initiatives, which have been developed in response to NTSB recommendations. These discussions included lessons learned from past accident investigations and track inspection oversight activities that the industry can employ to improve track worker safety.

12th Annual SSO Meeting

Atlanta, Georgia

FTA held the 12th Annual SSO Program Meeting, September 8 to 11, 2008 in Atlanta, Georgia. The meeting was co‐hosted by the Georgia Department of Transportation (GDOT) and the Metropolitan Atlanta Rapid Transit Authority (MARTA).

There were 90 attendees at this year’s meeting, including:

• 40 rail transit agency representatives
• 27 state oversight agency representatives
• 10 FTA regional representatives
• 10 Industry representatives and support staff
• 3 FTA HQ representatives

Meeting topics included many issues that currently face the SSO Community, such as:

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• Hazard management
• Accident investigation
• Oversight agency and transit agency organization issues
• Efficiency testing
• Wayside worker protection
• Addressing NTSB recommendations
• Internal security audits

FTA was very pleased to have Dr. Beverly Scott, MARTA General Manager, and Mr. John Catoe, Jr., General Manager of the Washington Metropolitan Area Transportation Authority (WMATA), deliver presentations on the role of executive management in building a safety culture within a transit agency.

On Tuesday, MARTA officials also provided Annual Meeting participants with a guided tour of the MARTA rail system. MARTA guides escorted participants through MARTA maintenance facilities and the MARTA yard tower, and provided access to emergency response units including MARTA SWAT and K9 personnel.

FTA will distribute materials from the Annual Meeting on CD‐ROM to the entire SSO Community.

MARTA Station

CEO Safety Summit

Washington, DC

On July 23 to 24, FTA conducted a Safety Summit with Chief Executive Officers (CEOs) from 36 rail transit agencies and representatives from the NTSB, SSO agencies, and Norfolk Southern Railroad. Approximately 70 people attended the event, held at L’Enfant Plaza in Washington, DC.

Administrator Simpson called the Safety Summit to facilitate discussion with the rail transit industry’s executive leadership regarding emerging safety concerns in industry, including wayside worker fatalities and injuries, operating and maintenance rules violations, and an increasing number of derailments.

The Summit included presentations by Mr. John Catoe, Jr., General Manager of the Washington Metropolitan Area Transportation Authority (WMATA), Mr. Ron Huberman, President, Chicago Transit Authority (CTA), Mr. Howard H. Roberts, Jr., President, New York City Transit, and Mr. Al Fazio, General Manager, New Jersey Transit River Line. The Summit also featured presentations by two SSO Program Managers, Mr. John Contestabile, Maryland Department of Transportation MDOT (MDOT)/Tri‐State Oversight Committee (TOC) and Ms. Georgetta Gregory, California Public Utilities Commission (CPUC).

On the first day of the Summit, Mr. Bob Chipkevich, Director, Office of Railroad, Pipeline and Hazardous Materials, NTSB provided an overview of the major rail transit accidents that NTSB has investigated over the past few years, and explained each of the recommendations that have been made to both

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the rail transit agencies and FTA. NTSB is especially interested in hours of service rules for the rail transit industry and in enhancing the authority and effectiveness of the SSO program.

Mr. Catoe shared his experience over the last year in taking the steps needed to strengthen safety culture and performance and make major changes at WMATA in response to the NTSB investigations and recommendations. Mr. Catoe raised the following issues such as recognizing gradual changes to operating conditions, getting “out in front” of safety problems publicly, and leadership acceptance of responsibility and commitment to solving and tracking problems. Mr. Catoe emphasized the importance of top‐down leadership and accountability, and direct communication with employees. He also shared the importance of rules enforcement programs and agency‐wide participation.

Mr. Huberman discussed his experience over the past year at CTA dealing with aging vehicle fleets and crumbling track structure, a significant number of slow zones necessitated by poor track conditions, and the antiquated block signal system. Mr. Huberman noted that, since coming to CTA, he has focused on changes in six key areas:

• Investing in infrastructure renewal
• Getting the organizational structure right
• Analyzing the process
• Using the right tools and technology
• Training
• Auditing

Mr. Contestabile emphasized the importance of transit agency and SSO agency partnerships and identified ways in which the rail transit CEOs could support the SSO program, including annual meetings with the SSO agencies, committing resources to an effective internal safety audit process, and addressing

SSO agency three‐year safety review findings in a timely manner.

Ms. Gregory discussed safety leadership, and how rail transit CEOs can show their commitment to safety in their organizational structures, budgets, rulebooks, training programs, and internal audit programs – in short by developing a strong safety culture.

Mr. Roberts reviewed NYCT’s accident history, noting that, on average, one wayside worker has been killed each year at NYCT since 1950 and a more in‐depth review of the two worker fatalities in April 2007 (resulting from two separate accidents just four days apart). These two accidents created a crisis at the agency and provided Mr. Roberts with the momentum to take unprecedented steps to improve wayside worker safety.

Mr. Roberts added TWU‐Local 100 to the Board of Inquiries conducting accident investigations and helped to create a joint labor‐management taskforce to review rail worker safety and make recommendations. The process used by the task force included a review of investigation reports; development of employee focus groups, including train operators and wayside workers; employee telephone surveys; a safety audit of flagging operations in the field; a review of training and employee monitoring practices; and an in‐depth rules review.

NYCT employee surveys revealed significant safety concerns. Field inspections also identified clear deficiencies in flagging activities, including adjacent track flagging, caution lights and portable train trip positioning relative to the work area, and poor compliance with the flagging requirements identified during the pre‐job inspection.

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To address findings, NYCT implemented extensive rules changes for flagging operations, particularly those relating to individuals, pairs, and small groups moving from point to point. NYCT also created a centralized flagging unit. All scheduled work requiring flagging must be flagged by centralized flagging unit personnel. New procedures will be developed for supervising and evaluating flaggers and for ensuring that this unit can address emergency flagging needs. New rules clarify that only qualified flaggers can flag and that, in the event a qualified flagger is not available to flag, work cannot be performed.

Mr. Roberts identified deficiencies that NYCT found with its job safety briefings and he explained the development of a pocket checklist used to conduct pre‐job safety meetings and review required activities. Mr. Roberts also explained the various rule revisions and procedures development undertaken by NYCT to address the identified issues, including noise abatement, communication with MOW employees, performance of inspections and audits, job safety briefings, and training.

The CEO Safety Summit concluded with a roundtable discussion facilitated by Mr. Fazio. The roundtable discussion focused on the following issues:

• Weaknesses in the development of safety rules and rulebooks
• Using the hazard management process to assess operating and maintenance practices
• Incorporate efficiency checks and behavioral based safety checks into progressive discipline
• Avoiding the “get it and go” mindset
• Poor productivity increases hazards
• Setting the tone for quality work
• Wellness programs
• Need for Federal support for hours of service regulation
• Addressing wayside worker safety during design and construction

NYCT employee surveys revealed significant safety concerns:

• Near miss incidents are frequent and most go unreported due to a fear of reprisal, a feeling that “nothing will get done,” or not wanting to get a coworker in trouble.
• There is a perception that employees that only perform flagging jobs are much better flaggers, and as a result flagging for contractors is stronger than flagging for employees.
• Safety rules are thorough but are not followed in the field.
• Train traffic on adjacent tracks is dangerous and not adequately addressed in the rules.
• Communication with OCC and Towers regarding the location of work crews is not adequately addressed in the rules.
• Train operators are not following rules to slow or stop on approach to work crews. Yellow lamps or flags are not placed at the leaving end of the station to remind train operators that they are still within a work zone.
• Different groups of workers interpret flagging rules differently.
• Inadequate flagging protection for inspectors and small groups working point‐to‐point.
• Emergency alarms and telephones were not working.

SSO Audit Program

Effective Practices

The Federal Transit Administration (FTA), Office of Safety and Security conducts audits of State Oversight Agencies (SOA) to assess compliance with 49 CFR Part 659, FTA’s State Safety Oversight (SSO) Rule. In addition to ensuring compliance, FTA also uses the audit program to gather effective practices and communicate them to SOAs and rail transit agencies in the SSO community.

The list on the right provides effective practices gathered during recent SSO audits. FTA will continue to provide SOAs with effective practices gathered during SSO audits through this newsletter, guidance documents, and SSO workshops and program meetings.

FTA will conduct an SSO audit of the following SOAs over the next 13 months:

• New York PTSB
• North Carolina DOT
• New Jersey DOT
• Colorado DOT
• Utah DOT
• Oregon DOT
• Washington State DOT
• Wisconsin DOT
• Minnesota DPS

• Quarterly SSO Program Meeting: The SOA chairs a quarterly SSO Program meeting attended by SOA staff and RTA safety personnel. The SOA documents the sessions in meeting minutes.
• SOA participation in RTA safety meetings: The SSO Program Manager attends and observes RTA safety meetings. While the SOA representative cannot vote, he/she can create agenda items.
• The Program Standard is maintained as a Living Document: The SSO Program Manager makes draft revisions to the Program Standard and formally incorporates changes annually.
• Online Hazard Tracking Database: The RTA tracks all hazards using an online database and has granted the SSO Program Manager review access.
• SOA participation in RTA internal audits: SOA representatives provide onsite support.
• SOA onsite presence: SOA representatives conduct frequent onsite inspections, help to identify hazards, and maintain a consistent onsite presence at the RTA.
• Review of Dispatcher Logs: The RTA Safety Department conducts daily reviews of dispatcher logs to identify hazards.