OPERATIONS INCIDENT REPORT OF AUGUST 6 DERAILMENT OVERVIEW

Transcription

1 OPERATIONS INCIDENT REPORT OF AUGUST 6 DERAILMENT OVERVIEW WMATA s investigation into the derailment on August 6, 015 is a multi-step process, culminating in a final report which will be submitted to the Tri-State Oversight Committee for their review and approval. The Investigation The attached report represents the first step in the investigation process a technical review of the incident, documented as an Incident Report from the Deputy General Manager of Operations (DGMO) Rob Troup to the Interim General Manager Jack Requa. This report reflects the investigation efforts conducted by the engineering, operational and maintenance disciplines within the DGMO organization, and includes important data such as field measurements, interview reports and voice recordings, as well as other evidence. As is normal practice, personal details have been redacted. The DGMO report has been submitted to WMATA s Chief Safety Officer to be considered as part of the Safety Department s investigation, which is expected to be completed in 30 days, and is subject to final review and approval by the Tri-State Oversight Committee (TOC). The Technical Report The purpose of this report is to develop an assumption of reasonable cause to ensure that there are no imminent hazards or safety concerns and also to develop early action items in response to findings. The report finds that the root cause of the derailment is failure of the rail fasteners that hold the rail in place, which resulted in the rail spreading wide enough for a wheel axle to drop between the rails. The wide gauge rail spreading condition was a contributing factor to the derailment. WMATA s track geometry vehicle (TGV) identified the wide gauge defect on July 9 th, along with three other similar Level Black track defects. A Level Black defect is a defect that needs to be addressed immediately because the track is at risk of failure if operations continue. However, the TGV technician erroneously deleted the defect from his exception report, believing it to be a routine anomaly, such as those he is trained to see and delete in interlockings. However, the remaining three Level Black defects found by the TGV were properly identified, reported, and repaired. The purpose of the exception report is to provide immediate information for the scheduling of necessary maintenance actions. The report also indicates a failure of WMATA s quality check process. WMATA tracks are maintained to a specific engineering standard and are subject to multiple layers of inspection including visual inspections by track walkers, measurements taken by the TGV, and the operator s exception report from the operator as well as the raw data from the TGV. All of these sources are subject to coordinated, efficient analysis and then sorted for follow-up action based on an assessment of risk to railroad operations. This investigation revealed the lack of a system that required, at the end of each TGV run, comparison by the operator and a manager of the operator s exception report and raw data collected and stored by the TGV. 1

2 Actions Taken by Management Since identifying the issues revealed in this report, WMATA management has taken action in three key areas to improve the safety of the rail system: immediate safety actions to improve track safety, overhaul quality processes to prevent recurrence and accept responsibility for the safety failures that preceded the incident. Immediate safety actions Speed restrictions placed on tight curves, which are being inspected. Where necessary, replacement of older style fasteners in the system on the outer rail have been initiated. All curves will be inspected by both the TGV and close visual inspection by track walkers. By September 1, the TGV will have completely re-inspected the entire rail system. Following the TGV is a chase vehicle with a maintenance crew and materials to immediately verify and address any level black defect which may be identified. As this process is completed, Metro can develop a new baseline of the system, insuring that any previous exceptions had not been deleted. Prevent Recurrence/Enhance Quality Assurance On-board functions for the TGV and its technicians have been revised and now include a thorough review of the test results with an area manager prior to generation of the final exception report. This will cross-reference the exception report against the raw data exceptions which will ensure that all positive exception defects have been correctly identified and retained. Final exception reports are being provided to maintenance manager(s) at end-of-run. This provides for the quality check of the exception data immediately by the inspection team and insures that the maintenance team that is responsible for correction is receiving the most reliable data. The TGV crew now has authority, as a result of immediate confirmation of severity and accuracy of detected defect, to remove the track from service until repairs have been effected prior to revenue service. This provides another quality check and integration point between the inspection team and maintenance team. After each run of the TGV, an Exceptions Sheet is provided to track maintenance, engineering, and quality assurance staff, which provide written feedback to track maintenance on analysis of exceptions requiring service adjustment (speed restriction, track out of service) identified by TGV geometry run(s). This provides a tertiary check of data by additional departments to insure that no exception requiring an action has been lost. A third-party expert has been retained to provide a comprehensive report that includes a review of the derailment data and wheel/rail interface issues, and to ensure that the technical conclusions of the DGMO report are correct.

3 Working with the outside expert, a number of engineering and design assumptions will be reanalyzed to assist in pinpointing contributing factors to rail component condition, including rail and fasteners. Staff is also developing a TGV-programmed algorithm to improve defect confirmation and automatic work order loading, which will support the new check and balance system being implemented. Based on the known location of certain recurring anomalies, this will complement the human interface element much like a are you sure you want to delete interface point prompted by the program. Accept Responsibility Safety stand-downs, or brief stoppages in work for safety critical meetings, with track and structures personnel are on-going to reinforce TGV and track walker purpose and expectations, and to re-educate on the complimentary nature and intentional redundancy of TGV and visual inspections. This is being done to re-emphasize the importance of walking track inspections, that the TGV is complementary to, not a replacement of, the visual inspections. Next Steps Operating under Federal Transit Administration (FTA) regulations and guidance, the Tri-State Oversight Committee (TOC) has delegated the investigation to WMATA s Safety Department (SAFE). A draft SAFE investigation will be conveyed to the TOC for its review in late September. The investigation and report are finalized following review and approval by the TOC. Further, the General Manager directed the Chief Safety Officer to review the role of his Department with respect to the incident, and to specifically assess SAFE s role prior to and during the incident, as well as follow up actions taken after August 6. This includes a review of Safety s role in the development of check and balance procedures for the introduction of new equipment. Management will update the Board on the investigation and any further actions taken at the special meeting of the Board Safety Committee on September 3,

4 Washington Metropolitan Area Transit Authority Office the Deputy General Manager, Operations DGMO Incident Summary Report LOCATION: Federal Triangle to Smithsonian INCIDENT#: 01518BLUE3 DA TE: 08 I 06 /015 TIME: 05:0 Deputy General Manager, Operations

5 Table of Contents Executive Summary Incident Summary Report Investigation Team Members Incident Summary Incident Description Chronological Timeline Information... 6 Communication MTPD I SAFE I OEM Support Summary... 8 Cause and Remediation Moving Forward... 9 Photos and Figures Attachments Rev. 0.0 Page 1of This information is proprietary to the Washington Metropolitan Area Transit Authority (WMATA). No reproduction is allowed without prior consent.

6 Executive Summary On Thursday, August 6, 015, at approximately 050, it was reported that Train ID 1 (six cars: Lead Car 3157, 3156, 17, 173, 08, End Car 09) derailed between Federal Triangle (D01) and Smithsonian (D0) Track at chain marker D 0+1 while executing a crossover move from track to track 1. Based on the information gathered, five trucks came off of the rails. The train was being operated under manual mode traveling at a speed of approximately 15 mph. The train originated from New Carrollton Rail Yard as an employee train and was not yet in revenue service and carried no passengers. There were no reported injuries. Damage was contained to track, railcar wheels and trucks, and ancillary ATC and power devices. Because the train "fouled" both tracks significant disruption occurred on August 6th and August 7th (total shutdown and subsequent single tracking). Cause Failed fasteners on "high rail" in tight radius curve contributed by wide gauge issue. Based on the observations and determinations of the Point of Derailment (POD) on the low rail at D +1 and the subsequent wheel climb 8 feet beyond the POD on the high rail combined with the observance of loose, skewed and deteriorated fasteners, it can be assumed that the high rail spread outward enough to allow the low rail wheel to drop inside of the low rail and upon traveling toward the known wheel climb section, once the fasteners condition on the high rail improved, the outer wheel (high rail wheel) was forced upward and outward eventually tracking across the rail surface until it dropped off the outside of the rail soon after. Further support based on all the findings and determination of the facts of the final investigative review may impact this assumption. Potential Contributing Factors: Reported wide gage near point of derailment Loose or broken studs Track Dynamics caused by other factors (super elevation, attainable speed) Track Geometry Inspection process (walking and TGV) Preceding Contributory Factors: The wide gauge issue was identified during a Track Geometry Vehicle run on July 9th and repairs had not been effected prior to the derailment incident. As the TGV makes the geometry run, a technician monitors the data for "out of tolerance defects". This monitoring is important to provide an accurate "exception" report at the end of the run, as certain track components such as joints, frogs, and switch points will show in the raw data as out of tolerance for gauge, but are in fact are not defects. These "false exceptions" are deleted by the technician who is trained to be able to analyze the presented data and determine a "positive exception" and a "false exception". It is important to note that the data is deleted from the "exception" report, but never the raw data. At the end of the run the "Exception Report" is provided to maintenance for corrective action or, if necessary, removing the track from service. Rev. 0.0 Page of This information is proprietary to the Washington Metropolitan Area Transit Authority {WMATA). No reproduction is allowed without prior consent.

7 In this particular instance, level black "positive exceptions" should have been noted but the technician erroneously deleted one of those from the exception report and, as a result, the immediacy of the data was lost and the defect was not corrected. The remaining 3 noted defects were corrected according to policy. Recommendations 1. Immediately begin inspection and, where necessary, initiate the replacement of older style fasteners in the system on the outer rail in all curves with a radius less than 15'. Over the next four weeks the TGV will run through the entire system with a "chase vehicle". The chase vehicle contains a maintenance crew and materials to immediately verify and address any level black issue which may be identified by the TGV. This will allow for immediate disposition of crew and material to correct defects. After this initial run the chase vehicle will be on "standby" during the normal geometry testing runs. The chase vehicle will continue to run with the TGV during ultrasonic testing as is the current process to address internal rail defects. 3. On-board functions will now include a thorough review of the test results with an area manager prior to generation of the final exception report and release of the track(s) tested for full or restricted operations. This will cross-reference the exception report against the "raw data" exceptions which will ensure that "positive exception" defects have been correctly identified and retained. Final exception report shall be provided to maintenance manager(s) at end-of-run. This provides a QC check of accuracy of data and deletions.. The TGV crew will have authority, as a result of immediate confirmation of severity and accuracy of detected defect, to remove the track from service should repairs not be effected prior to revenue service. 5. At end of each run TRST Inspections to provide "Exceptions Sheet" to TRST Maintenance, TSFA Engineering and QAAW and provide written feedback ( w/ confirmation) to TRST Maintenance on analysis of exceptions requiring service adjustment (speed restriction, track out of service) identified by TGV geometry run(s) - Red, end of shift; Black, immediately upon discovery 6. Safety Stand-down with TRST (maintenance, inspection) to reinforce TGV and track walker purpose, expectations and fact that inspections are independent and complimentary to each other 7. Contract with third-party for wheel I rail interface expert to review derailment data 8. Continued engineering analysis of "unintended consequence" of WMA TA standard 56 %" gauge, super elevation design speeds greater than "attainable speed", and other "contributory design issues". 9. Investigate programmed algorithm for defect confirmation and automatic work order loading. Rev. 0.0 Page 3of This information is proprietary to the Washington Metropolitan Area Transit Authority (WMATA). No reproduction is allowed without prior consent.

8 Incident Summary Report LOCATION: Federal Triangle to Smithsonian INCIDENT#: 01518BLUE3 DATE: 08 I 06 /015 TIME: 05:0 Investigation Team Members TRST- Track Maintenance- Assistant General Superintendent, Superintendent. Assistant Superintendent, Superintendent Track & Way, Manager Track and Structures Maintenance CENV- Senior Vehicle Engineer- Rail Car, Vehicle Engineer- Rail Car SMNT- Shift Supervisor, Automatic Train Control Rev. 0.0 Page of This information is proprietary to the Washington Metropolitan Area Transit Authority (WMATA). No reproduction is allowed without prior consent.

9 Incident Summary On Thursday, August 6, 015, at approximately 05:0, it was reported that Train ID 1 (six cars: Lead Car 305, 3156, 17, 173, 08, End Car 09) derailed between Federal Triangle (D01) and Smithsonian (D0) Track at chain marker D 0+50 while executing a crossover move from track to track 1. Based on the information gathered, five trucks came off of the rails (the rear truck of car 17, both trucks of cars 173 and 08). The train was being operated under manual mode traveling at a speed of approximately 15 mph. The train originated from New Carrollton Rail Yard as an employee train. There was no damage to switch components. Incident Description On 08/06/015 at 05:0AM Operator was operating "Employee Train" Train ID 1. The lead consist was crossing over the Smithsonian Interlocking from D-06 Signal to clear D0-0 when Operator reported to ROCC the train would not move when taking a point of power. ROCC instructed Operator to Key Down, check Console Indications and associated C/B's, keyed back up and attempt to move train. The operator followed the instructions, but train would not move when taking power. Train Operator reported seeing smoke emitting from the train and said he felt the train had derailed. ROCC instructed Operator to secure the Cab and perform a walk around of the train. Operator reported that Car 173 Rear Truck was off the track. CMNT staff were dispatched to incident scene. They reported that train derailed in the interlocking. CMNT reported that Car 17 Rear Truck, 173 Front and Rear Trucks and Car 08 Front Trucks were derailed. CENV arrived on scene and conducted a walk around. Lead Cars 3157 and 3156 were on the Interlocking with Car 3157 on Track 1 and Car 3156 on Track, reference Figure 1. Married Pair 3157/56 and Car 09 did not derail. Third Car in consist was 17 and its Front Truck was on the rails, but the Rear Truck had the lead axle off the rails (reference Figure ) and the trailing axle on the rails (reference Figure 3). CENV also noted that axle 3 (wheel 5) on Car 17 had a broken Brake Rotor and was on the inside of the rail, reference Figure. Only the lead axles on cars 173 and 08 derailed. CENV observed that on Cars 173 and 08 the rail was located between the Wheel and Brake Rotor, reference Figure and 5. CENV also noted damaged Tie Bolts holding the Rail. Damage caused by the Brake Rotor hitting the bolts after the wheel dropped off the rail, reference Figure 6. FRA data shows the car had moved 900 feet from the point when car 3157 was keyed up. First movement was 13 feet. Second move was a total of 731 feet, with an estimated 88 feet Rev. 0.0 Page 5of This information is proprietary to the Washington Metropolitan Area Transit Authority {WMATA). No reproduction is allowed without prior consent.

10 being after train derailed. Train had a top speed of 16 mph and had a Regulated Speed Command of mph. Derailment appears to have occurred at 13 mph with Master Controller in P5 at 5:16:56 (FRA time), reference Figure 7. Deceleration rate of 1. mphps with Master Controller in 85. Another 6 feet of movement after derailment with top speed of 3 mph at 5:17:3. SMNT noted damage to impedance bond, WZ-6 CM D3+59. No interlocking equipment was impacted by the derailment. Chronological Timeline Information From VMS FRA Recorder : 05:16:5 (VMS FRA Time) Train ID 1 attained a max speed of 16MPH, see Figure 7. 05:17:00 (VMS FRA Time) Train ID 1 came to a stop. 05:17:30 (VMS FRA Time) Train ID 1 attained a speed of 3MPH. 05:17:50 (VMS FRA Time) Train ID 1 stopped on Interlocking. 05:17:5 to 05:1 :35 Operator moved Master Controller from PS and 85. Train speed OMPH, see Figure 3. Thursday August 6, 015: Report of derailment Track Superintendent arrived to scene On-Call Rail Engineer discussed going to scene of derailment with Manager TRST personnel allowed to begin assessment of track On-Call Rail Engineer arrived at Federal Triangle Platform briefing On-Call Rail Engineer meet Rail Engineers at Federal Triangle and begin derailment investigation PM0, PM7 and PM7 arrived in the work location 115- PM7 towed two train cars 305, 3156 from the work area Track personnel cleared track 1 to restore train service Rev. 0.0 Page 6of This information is proprietary to the Washington Metropolitan Area Transit Authority {WMATA). No reproduction is allowed without prior consent.

11 10 - Track personnel received permission to hot stick Track to continue re-railing of the trains 1- Test train cleared 001 Track 1 without incident Re-railing car Re-rail and coupled 08, 09, PM PM-0 has pulled 3 cars into Federal Triangle. Derailed car 17 is still on the track. CTEM reported approximately another hour until 17 is re- rail. Track damage is from +30 to +00. The low side with the F-0 Fasteners have broken studs in the gauge side and the high side with Lord Fasteners are broken on the third rail side. Cover boards are off within those chain markers as well On-Call Rail Engineer and Rail Engineer completed on scene investigation of derailment Re-rail. All derail rail cars transported out of the work area. PM35 standing by at New Carrollton yard, waiting for a lead to the work area. Friday August 7, 015: PM35 arrived to work location and work began. 0:9 - Personnel installed (1 ) fasteners on the high rail RR from +30 to 3+0, (1) cover boards installed. Work gang continued to pour and set studs Track unit 83 boarded test train 701 along with SAFE Unit 19 at Capital South Trk RWIC 619 relinquish work area to OCC Test train traveled to the C/A connector Test train departed CIA connector. OCC gave the operator a block to Smithsonian Trk1 crossing over Trk to Trk1 at McPherson Square interlocking Test train arrived at Smithsonian Trk Test train received a block to Federal Triangle Trk crossing over at Smithsonian interlocking Trk1 to Trk Track unit 83 and SAFE Unit 19 cleared derailment area and deemed area safe passage for revenue service. Rev. 0.0 Page 7of This information is proprietary to the Washington Metropolitan Area Transit Authority {WMATA). No reproduction is allowed without prior consent.

12 Communication SAFE, MTPD, and Track personnel were notified. MTPD I SAFE I OEM Support Summary No report available at this time. Rev. 0.0 Page 8of This information is proprietary to the Washington Metropolitan Area Transit Authority (WMATA). No reproduction is allowed without prior consent.

13 Potential Cause Note that the investigation is ongoing and the following represents actions which have been determined to have likelihood of contribution to the derailment. This is not intended to be a final determination of cause. The root cause failure is determined as follows: Broken fasteners at point of derailment on the "high rail" of the curve Other contributory factors may include: Reported wide gauge near point of derailment Loose or broken studs Note - there may be other contributory factors to the derailment which do not have to do with wide gauge. This will be determined in the final investigatory report. However, the initial investigation has revealed failures of TGV reporting and maintenance correction of defects as listed in the following "Preceding contributory factors" paragraph. Preceding contributory factors: The wide gauge issue was identified during a Track Geometry Vehicle run on July gth and repairs had not been effected prior to the derailment incident. As the TGV makes the geometry run a technician monitors the data for "exceptions". This monitoring is important to provide an accurate "exception" report at the end of the run as certain track components such as joints, frogs, and switch points will show in the raw data as exceptions but are in fact are not defects. These "false exceptions" are deleted by the technician who is trained to be able to analyze the presented data and determine a "positive exception" and a "false exception". It is important to note that the data is deleted from the "exception" report, but never the raw data. At the end of the run the exception report is provided to maintenance for corrective action or, if necessary, removing the track from service. In this particular instance, level black "positive exceptions" were noted but the operator erroneously deleted one of those from the exception report. As a result, the immediacy of the data was lost. The remaining 3 noted defects were corrected according to policy. Rev. 0.0 Page 9 of This information is proprietary to the Washington Metropolitan Area Transit Authority (WMATA). No reproduction is allowed without prior consent.

14 TRST Remedial Action Plan Action items to improve standing of track and related processes involving out of tolerance track conditions 1. Analyze curves with radius tighter than 15' for fastener condition. Over the next four weeks the unit will run through the entire system with a "chase vehicle". The chase vehicle contains a maintenance crew and materials to immediately verify and address any level black issue which may be identified by the TGV. This allow for immediate disposition of crew and material to correct defects. After this initial run the chase vehicle will be on "standby" during the normal geometry testing runs. The chase vehicle will continue to run with the TGV during ultrasonic testing as is the current process. 3. On-board functions will now include a thorough review of the test results with an area manager prior to generation of the final exception report and release of the track(s) tested for full or restricted operations. This will cross-reference the exception report against the "raw data" exception report which will insure that "positive exception" defects have been correctly identified and retained. Final exception report shall be provided at end-of-run. This provides a QC check of accuracy of data and deletions.. The TGV crew will have authority, as a result of immediate confirmation of severity and accuracy of detected defect, to remove the track from service should repairs not be effected prior to revenue service. 5. At end of each run TRST Inspections to provide "Exceptions Sheet" to TRST Maintenance, TSFA Engineering, SAFE and QAAW. Provide written feedback to TRST Maintenance on analysis of exceptions requiring service adjustment (speed restriction, track out of service) identified by TGV geometry run(s) as follows: Red - end of shift; Black - immediately upon discovery 6. Safety Stand-down with TRST (maintenance, inspection) to reinforce walking inspection procedures 7. Retain third party expert to review derailment data 8. Review track structure for "contributory design issues" which may accelerate deterioration. 9. Investigate programmed algorithm for defect confirmation and automatic work order generation Rev. 0.0 Page 10of This information is proprietary to the Washington Metropolitan Area Transit Authority (WMATA}. No reproduction is allowed without prior consent.

15 Figure 1 - Cars 3157 (Lead) and 3156 (Closest Car Seen) on Interlocking Rev. 0.0 Page 11of This information is proprietary to the Washington Metropolitan Area Transit Authority {WMATA). No reproduction is allowed without prior consent.

16 Figure - Car 17 Rear Truck Axle 3 (Leading Axle) Broken Rotor and Inside Rail Rev. 0.0 Page 1of This informotion is proprietary to the Washington Metropolitan Area Transit Authority (WMATA). No reproduction is allowed without prior consent.

17 Figure 3 - Car 17 Rear Truck Axle on Rail (Same on all Trucks) Figure - Car 173 and 08 Leading Axle with Rail between Rotor and Wheel Rev. 0.0 Page 13of This information is proprietary to the Washington Metropolitan Area Transit Authority {WMATA). No reproduction is allowed without prior consent.

18 Figure 5 - Car 173 and 08 Leading Axle with Rail between Rotor and Wheel (View ) Figure 6 - Track Damage when Wheel Dropped off Rail, Damage Done by Rotor Hitting Bolts Rev. 0.0 Page 1of This information is proprietary to the Washington Metropolitan Area Transit Authority (WMATA). No reproduction is allowed without prior consent.

19 Figure 7 - VMS FRA Speed and Master Controller Position Rev. 0.0 Page 15of This information is proprietary to the Washington Metropolitan Area Transit Authority (WMATA). No reproduction is allowed without prior consent.

20 Figure 8 - Damage to rail head Rev. 0.0 Page 16of This information is proprietary to the Washington Metropolitan Area Transit Authority {WMATA). No reproduction is allowed without prior consent.

21 Figure 9 - Point of derailment Rev. 0.0 Page 17of This information is proprietary to the Washington Metropolitan Area Transit Authority {WMATA). No reproduction is allowed without prior consent.

22 Name Attachment A TRST Incident Summary Preliminary Report... A Attachment A 1 TRST Other Summary Data A 1 Attachment B CENV Incident Summary Preliminary Report B Attachment C Approved Incident Report, Incident ID: 01518BLUE MOC Assistance Superintendent Shift Summary, 8/5-6/ Oracle Analysis, D0 Derailment D D0 Derailment ATC Findings report, 8/10/ Maximo W.0# D01 Derailment Response and Repairs TKIN Acting Superintendent Statement, 8/1/ TGV Tech Statement Exception Reports Safety Order Track Inspection... D0 () Switch Inspections... 3 D0 () Switch Inspections... 7 FW_ July 015 TGV Exception reports Track Chart D CM CM TRST Defect report TRST Track Walker Report A TRST Track Walker Report B TRST Track Walker Report A... 0 TRST Track Walker Report Op tram Gauge Rod Locations Optram Geometry D CM 1+8-CM Optram Geometry Trend D CM 1+8-CM Optram Profiles D CM 1+8-CM Optram Profiles Trend D CM 1 +8-CM GeoEdit D CM +00-CM Rev. 0.0 Page 18of This information is proprietary to the Washington Metropolitan Area Transit Authority {WMATA). No reproduction is allowed without prior consent.

23 ATTACHMENT A

24 Washington Metropolitan Area Transit Authority TRST Summary Report TRST Incident Summary Preliminary Report to 00 Track Derailment LOCATION: Federal Triangle to Smithsonian 0 +1 INCIDENT #: 01518BLUE3 DATE: 08 I 06 /015 TIME: 050

25 Washington Area Metropolitan Transit Authority Incident Summary Report Table of Contents Investigation Team Members Incident Description Chronological Timeline Information Communication MTPD I SAFE I OEM Support Summary Cause and Recommendation Photographs Attachment A Rev. 0.0 TOC This information is proprietary to the Washington Metropolitan Area Transit Authority (WMATA). No reproduction is allowed without prior consent.

26 Washington Area Metropolitan Transit Authority Incident Summary Report Investigation Team Members Investigation Team Members TRST- Track Inspections- Assistant General Superintendent, Division Superintendent; Track Maintenance- Assistant General Superintendent, Superintendent, Assistant Superintendent, Superintendent Track & Way, Manager Track and Structures Maintenance Incident Description On Thursday, August 6, 015, at approximately 050, it was reported that Train ID 1 (six cars: Lead Car 3157, 3156, 17, 173, 08, End Car 09) derailed between Federal Triangle (D01) and Smithsonian (D0) Track at chain marker D 0+1 while executing a crossover move from track to track 1. Based on the information gathered, five trucks came off of the rails. The train was being operated under manual mode traveling at a speed of approximately 15 mph. The train originated from New Carrollton Rail Yard as an employee train. There was no damage to switch components. Chronological Timeline Information August 6, Report of derailment Track Superintendent arrived to scene TRST personnel allowed to begin assessment of track PM0, PM 7 and PM7 arrived in the work location PM7 towed two train cars 3157, 3156 from the work area Track personnel cleared track 1 to restore train service 10 - Track personnel received permission to hot stick D01 D Track to continue re-railing of the trains 1 - Test train cleared D01 Track 1 without incident Re-railing car Re-rail and coupled 08, 09, PM PM-0 has pulled 3 cars into Federal Triangle. Derailed car 17 is still on the track. CTEM reported approximately another hour until 17 is re- rail. Track damage is from +30 to +00. The low side with the F-0 Fasteners have broken studs in the gauge side and the Rev. 0.0 Pagel of This information is proprietary to the Washington Metropolitan Area Transit Authority (WMATA}. No reproduction is allowed without prior consent.

27 Washington Area Metropolitan Transit Authority Incident Summary Report high side with older fasteners broken on the third rail side. Cover boards are off within those chain markers as well Re-rail. All derail rail cars transported out of the work area. PM35 standing by at New Carrollton yard, waiting for a lead to the work area. Friday August 7, PM35 arrived to work location and work began.09- Personnel installed (1) fasteners on the high rail RR from +30 to 3+0, (1) cover boards installed. Work gang continued to pour and set studs Track unit boarded test train 701 along with SAFE Unit at Capital South Trk RWIC relinquish work area to OCC Test train traveled to the C/A connector Test train departed C/A connector. OCC gave the operator a block to Smithsonian Trk1 crossing over Trk to Trk1 at McPherson Square interlocking Test train arrived at Smithsonian Trk Test train received a block to Federal Triangle Trk crossing over at Smithsonian interlocking Trk1 to Trk Track unit and SAFE Unit cleared derailment area and deemed area safe passage for revenue service. Communication SAFE, MTPD, and Track personnel were notified. MTPD I SAFE I OEM Support Summary No report available at this time. Rev. 0.0 Page of This information is proprietary to the Washington Metropolitan Area Transit Authority (WMATA). No reproduction is allowed without prior consent.

28 Cause and Recommendation Washington Area Metropolitan Transit Authority Incident Summary Report TRST conducted a track inspection of the derailment area, once the affected vehicles were removed from the scene, which included the entire section of curved track between Federal Triangle Station and Smithsonian Station D CM to D CM +68 which is located at the Point of Switch 38 D0 Interlocking; measurements are included in attachment "First Gauge Measurements Federal Triangle.pdf'. In summary, the measurements indicate the Point of Derailment (POD) to be D CM +00 based on initial offsets of chain marker signs. The measurements were later determined to be inaccurate, and crossed referenced to match CENV recording points which accurately determine the POD to be D +1 and illustrated in Figure 1. All parties agreed on the POD of the wheel dropping in gauge to be +1 (inside rail). Approximately 8 feet beyond the POD at D CM +9 (outer rail) is evidence of a wheel climb indicated by surface scrapes along the top of the right running rail (High Rail) initiating from a point just above the gauge face outward to the field side of the rail as illustrated in Figure. Figure 3: illustrates additional evidence to support the location of the POD based on observation of the first damaged stud near the POD of the last axle to drop off the low rail as pictured. Figure : the fasteners are skewed into an abnormal orientation other than perpendicular to the running rail. This location initiated just prior to the POD. There were 10 successive fasteners which were either skewed or damaged at this location. CENV provided video which demonstrates the start of this fastener condition approximately fasteners prior to the POD. Figure 5: simply identifies an installation of new fasteners spread throughout the affected area near the POD which helps define the rigidness or soundness of the low ra il and support hardware. Upon notification of the incident, a review of the Geometry Surveys was conducted to determine the last known measurements of the track structure prior to the derailment. The track was surveyed on July 9, 015 by WMATA Track Geometry Vehicle GV-01 and Run ID: _0 generated and attached to this report. TRST utilizes the software program Optram to quickly display and reference information loaded from the TGV and the Enterprise Asset Management System Maximo. Initial observations of the affected area in Optram indicated a wide gauge exception as displayed in the Visual Strip Chart (VSC) display lane of the TGV Geometry preference file. The TGV Gauge defect lane just below the VSC lane did not indicate a wide gauge exception. This was later determined to be a result of an incidental deletion of the exception from the exception report support csv file. It is important to know a deletion in this file does not eliminate it from Rev. 0.0 Page 3of This information is proprietary to the Washington Metropolitan Area Transit Authority (WMATA). No reproduction is allowed without prior consent.

29 Washington Area Metropolitan Transit Authority Incident Summary Report the "raw" data csv file which populates the VSC lane. An acknowledgement of the deletion by the console operator was documented and acted upon by TRST management. Based on the observations and determinations of the POD on the low rail at 0 +1 and the subsequent wheel climb 8 feet beyond the POD on the high rail combined with the observance of loose, skewed and deteriorated fasteners, it can be assumed that the high ra il spread outward enough to allow the low rail wheel to drop inside of the low rail and upon traveling toward the known wheel climb section, once the fasteners condition improved, the outer wheel (high rail wheel) was forced upward and outward eventually tracking across the rail surface until it dropped off the outside of the rail soon after. Further support based on all the findings and determination of the facts of the final investigative review may impact this assumption. All supporting documentation related to TRST investigation is included for reference as to the investigation progresses. Summary of Pertinent Facts: Ten fasteners on the outer rail were identified as skewed with broken or loose hold down bolts just prior to and beyond the POD. The fasteners are the older style fasteners which were identified in 013 to be replaced due to estimated life-cycle Two cars traveled over the area prior to the first derailed car Forces applied to the rail section by the first two cars was determined (by CENV) to be approximately two times the value of the first derailed car Cause The investigation is an ongoing effort to determine the root cause(s) of the derailment. Primary point of failure is considered to be: Failed fastener system on outer rail proximate to and within the derailment zone Potential Contributing Factors Reported wide gauge near point of derailment Loose or broken studs Failed or deteriorating fasteners (outer rail) Track Dynamics caused by other factors (super elevation, attainable speed) Track Geometry Inspection process (walking and TGV) Preceding Contributory Factors: The wide gauge issue was identified during a Track Geometry Vehicle run on July 9th and repairs had not been effected prior to the derailment incident. Rev. 0.0 Page of This information is proprietary to the Washington Metropolitan Area Transit Authority (WMATA). No reproduction is allowed w ithout prior consent.

30 Washington Area Metropolitan Transit Authority Incident Summary Report As the TGV makes the geometry run a technician monitors the data for "out of tolerance defects". This monitoring is important to provide an accurate "exception" report at the end of the run as certain track components such as joints, frogs, and switch points will show in the raw data as out of tolerance for gauge, but are in fact are not defects. These "false exceptions" are deleted by the technician who is trained to be able to analyze the presented data and determine a "positive exception" and a "false exception". It is important to note that the data is deleted from the "exception" report, but never the raw data. At the end of the run the "Exception Report" is provided to maintenance for corrective action or, if necessary, removing the track from service. In this particular instance, level black "positive exceptions" should have been noted but the technician erroneously deleted one of those from the exception report and, as a result, the immediacy of the data was lost and the defect was not corrected. The remaining 3 noted defects were corrected according to policy. Rev. 0.0 Page 5of This information is proprietary to the Washington Metropolitan Area Transit Authority (WMATA). No reproduction is allowed without prior consent.

31 Recommendations Washington Area Metropolitan Transit Authority Incident Summary Report 1. Inspect curves with radius less than 15' and, where necessary, immediately initiate the replacement of older type fasteners in the system on the outer rail in all curves with a radius less than 15'. Over the next four weeks, the TGV will run through the entire system with a "chase vehicle". The chase vehicle contains a maintenance crew and materials to immediately verify and address any level black issue which may be identified by the TGV. This will allow for immediate disposition of crew and material to correct defects. After this initial run the chase vehicle will be on "standby" during the normal geometry testing runs. The chase vehicle will continue to run with the TGV during ultrasonic testing as is the current process to address internal rail defects. 3. On-board functions will now include a thorough review of the test results with an area manager prior to generation of the final exception report and release of the track(s) tested for full or restricted operations. This will cross-reference the exception report against the "raw data" exceptions which will ensure that "positive exception" defects have been correctly identified and retained. Final exception report shall be provided to maintenance manager(s) at end-of-run. This provides a QC check of accuracy of data and deletions.. The TGV crew will have authority, as a result of immediate confirmation of severity and accuracy of detected defect, to remove the track from service should repairs not be effected prior to revenue service. 5. At end of each run TRST Inspections to provide "Exceptions Sheet" to TRST Maintenance, TSFA Engineering and QAAW and provide written feedback ( w/ confirmation) to TRST Maintenance on analysis of exceptions requiring service adjustment (speed restriction, track out of service) identified by TGV geometry run(s) - Red, end of shift; Black, immediately upon discovery 6. Safety Stand-down with TRST (maintenance, inspection) to reinforce TGV and track walker purpose, expectations and fact that inspections are independent and complimentary to each other 7. Retain third-party engineering expert to review derailment data 8. Continued engineering analysis of "unintended consequence" of WMATA standard 56 X" gauge, super elevation design speeds greater than "attainable speed", and other "contributory design issues". 9. Investigate programmed algorithm for defect confirmation and automatic work order loading. Rev. 0.0 Page 6of This information is proprietary to the Washington Metropolitan Area Transit Authority (WMATA). No reproduction is allowed without prior consent.

32 Washington Area Metropolitan Transit Authority Incident Summary Report Other less relevant impacts/actions resulting from derailment: The derailment damaged third rail cover boards, 15-0 third rail insulators, and 0 fasteners. Track personnel completed temporary repairs to restore service, reference Maximo W.O. # (attached). Rev. 0.0 Page 7of This information is proprietary to the Washington Metropolitan Area Transit Authority {WMATA). No reproduction is allowed without prior consent.

33 Washington Area Metropolitan Transit Authority Incident Summary Report Photographs Figure 1 TRK 0 CM 00+1 Point of derailment - Left Rail (LOW RAIL) Rev. 0.0 Page 8of This information is proprietary to the Washington Metropolitan Area Transit Authority (WMATA). No reproduction is allowed without prior consent.

34 Washington Area Metropolitan Transit Authority Incident Summary Report Figure TRK 0 CM Evidence of wheel flange riding on ball of the running rail; Right Rail (HIGH RAIL); approximately 8 feet beyond Point of Derailment. Note evidence of rail movement on fastener beyond wheel climb marks and missing hardware. Rev. 0.0 Page 9of This information is proprietary to the Washington Metropolitan Area Transit Authority {WMATA). No reproduction is allowed without prior consent.

35 Washington Area Metropolitan Transit Authority Incident Summary Report Figure 3 TRK D CM+1 - Car 17 brake disc resting on rail at Point of Derailment POD (last derailed axle); important to note evidence of 1 51 damaged stud from initial derailed axle on car 17. Rev. 0.0 Page 10of This information is proprietary to the Washington Metropolitan Area Transit Authority {WMATA}. No reproduction is allowed without prior consent.

36 Washington Area Metropolitan Transit Authority Incident Summary Report Figure View beneath Car 08 with rail wheel resting on Right Running Rail (High Rail); evidence of misaligned or twisted fasteners (10 in a row); location of outer rail movement near the POD. Rev. 0.0 Page 11of This information is proprietary to the Washington Metropolitan Area Transit Authority (WMATA}. No reproduction is allowed without prior consent.

37 Washington Area Metropolitan Transit Authority Incident Summary Report Figure 5 Damaged Studs beyond POD; evidence of new fasteners on Left Rail (LOW RAIL) which were installed in the fall/winter 01. Rev. 0.0 Page 1of This lnformotion is proprietary to the Washington Metropolitan Area Transit Authority {WMATA). No reproduction is allowed without prior consent.

38 Washington Area Metropolitan Transit Authority Incident Summary Report Attachments A 1 TKIN Track Walker AA Statement TKIN Track Walker D Statement First Gauge Measurements Federal Triangle.pdf 0 Exception Report Run ID _0 D Line Derailment Investigation Measurements Rev. 0.0 Page 13of This information is proprietary to the Washington Metropolitan Area Transit Authority {WMATA}. No reproduction is allowed without prior consent.

39 ATTACHMENT A.1

40 Question # 1: Please state your name for the record. A: Question# : What is your current Job classification? A: Track Walker AA Question # 3: How long have you been in your roll? A: Since1999 Question# : What has been your assigned inspection area for the past thirty days if not the same areas please list all them? A: Rosslyn to Capitol South (C05-D05) Tracks 1& Question# 5: What was your assigned inspection area on August 01 and August 5th, 015? A: A: Rosslyn to Capitol South Track #1 Question# 6: Did you inspect between 0 01 to 00 track on August 5th A: Yes, I was the RWIC was inspector. Question# 7: Do you walk with an inspection database during your daily inspections? A: Yes lljtjreallmllm 11'811il ldllfib Question #8 Who keeps the database during the inspection? A: The inspector Question # 9 : Was the database on your August 1 51, and August 5tti, 015 assigned inspection area reviewed? A: The database is reviewed. Question# 10: What were the tunnel conditions between Federal Triangle and Smithsonian on August 6 1 h, 015? A: Dry with poor lighting. We do wall< with flash lights. But the area was not totally dark. Question# 9: On the August 1 51 and August 5 1 ", inspp.ction whlk where there Any defects found in the arp.a of tr ack number two Smithsonian? A: Not to my knowledge, I was RWIC Al

41 Question # 10: Was your track inspection manual available to assist you in the inspection of your assigned inspection area? A: I am the RWIC so my sole duty is to be the watchman so I was carrying the RWP manual and the Roadway safety briefing forms. Question# 11. Where there any concerns in your assigned track inspection area of track # between Federal Triangle and Smithsonian found on August 15 1 and August 5 1 n. 015? A: There was nothing brought up to me about that area. Question # 1: If the inspection teams finds a serious condition. what methods would you use to safe guard the track to provide dependable service? A: Go by the track standard manual to make the area safe. Take actions like take the track out of service or slow the trains down. Question# 13: on August the 6 1 h. 015 did you notice any area that would warrant a speed restriction or more drastic measures? A: Not me as RWIC and nothing was bought to my attention. Question# 1: As the RWIC what would you do if you noticed an unsafe track condition? A: I would bring it to the inspector's attention from a place of safety. But for the record I didn't see anything that day. Question# 15: In the last 30 days has there been a time when your inspection between C05 and 005 been incomplete. A: Not that I recall.

42 Question# 1: Please state your name for the record. A Question# : What is your current Job classification? A: Track Walker 0 Question# 3: How long have you been in your roll? A: 6 months. Question# : Where you hired as a track walker? A: Yes. Question# 5: Prior to employment with WMATA did you have any rail road experience. A: Yes, with Delta construction. Question# 6: What has been your assigned inspection area for the past thirty days if not the same areas please list them all? A: It's been the same areas COS to 005 tracks 1& Question# 7: What was your assigned inspection area on August Pt. and August 5th 015? A: Rosslyn to Capitol South Question# 8: Did you inspect between 001 to 00 track on August 5 1 ". 015 A: Yes. W.lirlDtOI MetrOllOllml lroo TIBllll luttlolitv Question# 9: inspections? A: Yes Do you walk with an inspection database during your daily Question #10 Who keeps the database during the inspection? A: l do Question # 11 Was the database on your August 1 st. and August 5th. 015 assigned inspection area reviewed? A: Yes Question # 1: W hat were the tunnf!i r:nnditions between 1-ederal I nangle and Smithsonian on August 5 th. 01 5? ~,