Notation Id 8133C_6 Accident Date: 06/22/09 Issue Date: 08/10/10

City/State: Washington, DC NTSB Report #: RAR-10-02Most WantedList:

No

On Monday, June 22, 2009, about 4:58 p.m., eastern daylight time, inbound WMATA Metrorail train 112 struck the rear ofstopped inbound Metrorail train 214. The accident occurred on aboveground track on the Metrorail Red Line near the FortTotten station in Washington, D.C. The lead car of train 112 struck the rear car of train 214, causing the rear car of train 214 totelescope1 into the lead car of train 112, resulting in a loss of occupant survival space in the lead car of about 63 feet (about84 percent of its total length). Nine people aboard train 112, including the train operator, were killed. Emergency responseagencies reported transporting 52 people to local hospitals. Damage to train equipment was estimated to be $12 million.

Recommendation # : R-10-012 Overall Status:Open - AcceptableResponse

Priority: CLASS II

TO THE WASHINGTON METROPOLITAN TRANSIT AUTHORITY: Conduct a comprehensive safety analysis of theMetrorail automatic train control system to evaluate all foreseeable failures of this system that could result in a loss of trainseparation, and work with your train control equipment manufacturers to address in that analysis all potential failure modesthat could cause a loss of train detection, including parasitic oscillation, cable faults and placement, and corrugated rail.

# of Addressees: 1 Overall Date Closed: N/A

Addressee:WashingtonMetropolitan AreaTransit Authority

Open - AcceptableResponse

Date Closed: N/A

Recommendation # : R-10-013 Overall Status:Open - AcceptableResponse

Priority: CLASS II

TO THE WASHINGTON METROPOLITAN TRANSIT AUTHORITY: Based on the findings of the safety analysisrecommended in R-10-12 incorporate the design, operational, and maintenance controls necessary to address potentialfailures in the automatic train control system.

# of Addressees: 1 Overall Date Closed: N/A

Addressee:WashingtonMetropolitan AreaTransit Authority

Open - AcceptableResponse

Date Closed: N/A

Recommendation # : R-10-016 Overall Status:Open - AcceptableResponse

Priority: CLASS II

TO THE WASHINGTON METROPOLITAN TRANSIT AUTHORITY: Require that your safety department; representatives ofthe operations, maintenance, and engineering departments; and representatives of labor organizations regularly reviewrecorded operational data from Metrorail train onboard recorders and the Advanced Information Management system toidentify safety issues and trends and share the results across all divisions of your organization.

# of Addressees: 1 Overall Date Closed: N/A

Addressee:WashingtonMetropolitan AreaTransit Authority

Open - AcceptableResponse

Date Closed: N/A

Recommendation # : R-10-017 Overall Status:Open - AcceptableResponse

Priority: CLASS II

TO THE WASHINGTON METROPOLITAN TRANSIT AUTHORITY: Develop and implement a non-punitive safety reportingprogram to collect reports from employees in all divisions within your organization, and ensure that the safety department;representatives of the operations, maintenance, and engineering departments; and representatives of labor organizationsregularly review these reports and share the results of those reviews across all divisions of your organization.

# of Addressees: 1 Overall Date Closed: N/A

Addressee:WashingtonMetropolitan AreaTransit Authority

Open - AcceptableResponse

Date Closed: N/A

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Recommendation # : R-10-020 Overall Status:Open - AcceptableResponse

Priority: CLASS II

TO THE WASHINGTON METROPOLITAN TRANSIT AUTHORITY: Remove all 1000-series railcars as soon as possible andreplace them with cars that have crashworthiness collision protection at least comparable to the 6000-series railcars.

# of Addressees: 1 Overall Date Closed: N/A

Addressee:WashingtonMetropolitan AreaTransit Authority

Open - AcceptableResponse

Date Closed: N/A

Recommendation # : R-10-021 Overall Status:Open - AcceptableResponse

Priority: CLASS II

TO THE WASHINGTON METROPOLITAN TRANSIT AUTHORITY: Ensure that the lead married-pair car set of each train isequipped with an operating onboard event recorder.

# of Addressees: 1 Overall Date Closed: N/A

Addressee:WashingtonMetropolitan AreaTransit Authority

Open - AcceptableResponse

Date Closed: N/A

Recommendation # : R-10-022 Overall Status:Open - AcceptableResponse

Priority: CLASS II

TO THE WASHINGTON METROPOLITAN TRANSIT AUTHORITY: Develop and implement a program to monitor theperformance of onboard event recorders and ensure they are functioning properly.

# of Addressees: 1 Overall Date Closed: N/A

Addressee:WashingtonMetropolitan AreaTransit Authority

Open - AcceptableResponse

Date Closed: N/A

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