• Non-revenue derailment at Smithsonian

  • Discussion related to DC area passenger rail services from Northern Virginia to Baltimore, MD. Includes Light Rail and Baltimore Subway.
Discussion related to DC area passenger rail services from Northern Virginia to Baltimore, MD. Includes Light Rail and Baltimore Subway.

Moderators: mtuandrew, therock, Robert Paniagua

  by srepetsk
 
JDC wrote:What worries me is the speed restriction in place between L'Enfant and Pentagon, including over almost all of the Yellow line bridge. Shouldn't track issues have been spotted during the yearly (this past spring, I believe) inspection of the bridge? Or, is that just for the piers and structural components?
I went down that direction on Monday (Pentagon -> L'Enfant) and apparently had a different experience from what others are saying. The train limited to 20mph on the curves, and I noted we got up to just over 50 on the bridge itself before the overspeed alarm sounded.
  by MCL1981
 
JDC wrote:What worries me is the speed restriction in place between L'Enfant and Pentagon, including over almost all of the Yellow line bridge. Shouldn't track issues have been spotted during the yearly (this past spring, I believe) inspection of the bridge?
Just like they spotted the wide gauge that caused this derailment a month before it happened.....
  by JDC
 
srepetsk wrote:WMATA has released its report on the derailment: http://www.wmata.com/about_metro/news/P ... aseID=5959" onclick="window.open(this.href);return false;

Read the full report: http://www.wmata.com/about_metro/board_ ... erview.pdf" onclick="window.open(this.href);return false;
Per the summary: "As noted in the report, the TGV operator responsible for the mistaken deletion has resigned and since the report, a supervisor has also resigned."
  by JackRussell
 
JDC wrote:
srepetsk wrote:WMATA has released its report on the derailment: http://www.wmata.com/about_metro/news/P ... aseID=5959" onclick="window.open(this.href);return false;

Read the full report: http://www.wmata.com/about_metro/board_ ... erview.pdf" onclick="window.open(this.href);return false;
Per the summary: "As noted in the report, the TGV operator responsible for the mistaken deletion has resigned and since the report, a supervisor has also resigned."
I saw this in the report:
Utilizing the jacking post on the low rail side of Railcar asset R 2048 (4th car of the consist) the rear truck where axle #3 derailed at POD i.e . CM 22+41 , CMNT crew relieved the pressure and weight of the railcar from the rail high and it was observed the rail gauge sprung back inwards approximately 2 inches. Then working alongside with Track CMNT crew placed track bars and rail jacks in position to hold the gauge in place while proceeding to re-rail the revenue equipment. This had to be established before CMNT could move the equipment back through that area.
My reading of this is that the exception was deleted because the technician believed it to be a "false positive". And that's a common problem with *any* type of fault detection - if there are too many false positives, then the warnings are ignored/deleted as people believe that all such instances are false positives. Or if there are false positives that are almost like other known false positives, people may incorrectly conclude that this too is a false positive. It sounds like this is what happened here. False positives are apparently "normal" in the vicinity of switches, and as we all know there is a switch right where the accident occurred.

I have seen stories about air crashes that were indirectly caused by too many false positives. There are intruder detection systems (i.e. burglar alarms) that sometimes come to be ignored if there are too many false positives. There are software systems to scan computer code for security vulnerabilities that sometimes spit out tons of false positives (making it harder to sift through and find real issues). If I put my mind to it, I could come up with a half a dozen other examples.

I have mixed feelings about having people resign when there is a problem like this. If the technician was following the normal rules and procedures, then it smells like making someone a scapegoat instead of addressing the issues that lead to technicians being instructed to delete issues without enough analysis.
  by jkovach
 
The WMATA report states that the track geometry vehicle operator erroneously flagged the defect that caused the derailment as a false positive when he should have flagged it as an actual defect, but doesn't give any reasons as to why the operator may have made the error. Was it a simple "brain fart" or were there other contributing factors? Was the operator distracted / rushed / improperly trained / losing track of where he was on the railroad / etc? You can't do much about brain farts other than to have someone else cross check the work (which WMATA will start doing), but the other factors are potentially correctable and could also indicate an underlying issue of some sort. That's why it's important to rule them out.

Also I noted the following statement, which is relevant to the previous discussion of track gauge:
Recommendations

....

8. Continued engineering analysis of "unintended consequence" of WMATA standard 56 1/4" gauge, super elevation design speeds greater than "attainable speed", and other "contributory design issues".
Edit: As JackRussell points out, alarm overload is another possible (and potentially correctable) contributing factor!
  by JackRussell
 
jkovach wrote:The WMATA report states that the track geometry vehicle operator erroneously flagged the defect that caused the derailment as a false positive when he should have flagged it as an actual defect, but doesn't give any reasons as to why the operator may have made the error. Was it a simple "brain fart" or were there other contributing factors?
The implication from the report is that false positives are more frequent when going across crossovers/switches (for example, a frog), and the tolerances are slightly different there. But the TGV should *know* when it is looking at things like this and should be able to take this into account.

The other thing I got from the document was this:
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 14, 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.
This probably explains the speed restrictions that others have noted. On page 2 of the report there is a list of actions that they are taking to prevent a recurrence.

My inner English major is saddened by the spelling errors in the report - even in the paragraph that I cited. If that were the worst that one could say about Metro I would be happy.
  by MCL1981
 
Based solely on the report, which I read almost the whole thing... I'm not sure I fault the operator of the TGV very much here. This is a WMATA training and operational issue. The TGV flagged a wide gauge going through a switch. This guy was trained by WMATA to delete wide gauge flags going through switches. Frankly, I can't believe this kind of derailment isn't happening more often.
  by smallfire85
 
Now that the report's out, a couple of things need to be clarified. Please bear with a little too much explanation:

1. The interlocking had nothing to do with the derailment. The point of derailment (POD) was not at the switch, but about 200 feet beyond the nearest turnout in a curve. The train was making a reversing move from track 2 to track 1 when it derailed. If you look at the TGV exception report on page 49 of the report, you can see the line items of Frog and Switch Point in the report above (or in the test run, before) the wide gauge line item two lines from the bottom, which is near the POD. The lead cars of the train were in the middle of the interlocking, with the rest of the train on track 2 behind the interlocking. The train had to clear the interlocking on track 2 before making the move through the interlocking to track 1. If the train derailed in the interlocking, the reverse move would not have been possible because the train would not have been able to clear the interlocking with 5 derailed axles.

2.Looking at that same Exception report on page 49, you'll notice that two lines above the wide gauge defect is a gauge change defect of 1.5 inches over 26 feet at the same location.This itself is a black condition, and could be very well indicative of poor anchoring of one of the rails. The fact that the number is positive means that the gauge widened 1.5 inches in the direction the TGV was traveling, which was the direction of prevailing traffic (inbound,with the chain marker decreasing). A train traveling in the opposite direction would experience the opposite effect, with the gauge tightening a large amount over a short distance. This could produce a squeezing effect on the wheels and a subsequent derailment. This can also explain why one month of regular traffic went over this area without incident, but why one reversing move would have such devastating consequences. I'm pretty sure this defect was not deleted, which means that there should be record of the follow-up inspection of this defect and actions taken to bring the defect to at least a yellow condition. Theoretically, if the gauge change issue was resolved, the wide gauge issue should have also been resolved.

3. The TGV determines parameters like gauge by using lasers. In an interlocking, varying components such as the closure rails and the frogs produce anomalous readings, such as 59 inch gauge readings. However, these readings are usually over a very short distance and register as a "spike" on the readouts. EDIT: That are what these "false positive" statements are based on. Items like these would require a very complex software to identify, and the accuracy rate for this kind of detection would not be worth the cost of such development. Typically, items such as switch points, frogs, and platforms are manually input into the TGV during the inspection runs.

4. The gauge varies in different locations. In turnouts, the standard gauge is supposed to be 56.5". In tight curves, the gauge is widened slightly to reduce wear and the potential for a wheel climb. As was mentioned though, for tight curves like the one at the derailment location, anything over 57 inches is a slow speed order condition.

Personally, I believe the "wide gauge" and the accidental deletion explanation was a simple way to put a nice cover on a much deeper, systematic issue, as well as to provide an easy target to point a finger at. Realize that one of the recommendations was to give the TGV crew the authority to take tracks out of service if need be. The TGV crew should have had that power in the first place! The question becomes this: why, until now, did one of Metro's most sophisticated vehicles not have some sort of QA program in place, and why this program was given such little latitude to act on such bad findings?
  by Sand Box John
 
As point out above the train completely cleared and reversed direction before derailing. The POD was at 22+47, the points of turnout 3B on track D2 in the D03 interlocking is at 24+70.

24+70 is 223' south of the POD at 22+47, 22+47 is under Constitution Avenue. The D03 interlocking is located near mid block between Constitution Avenue and Madison Drive on the west side of 12th Street.
  by MCL1981
 
I see. That makes deleting the wide gauge flag a much more significant user-error.

The initial report of the wide gauge after the derailment painted a different picture. It sounded like Metro knew about it and simply ignored it for a month. Like "ya ya, we'll get to that some other time, keep the trains moving." That would be willful and borderline criminal negligence. Sadly, that notion was not surprising based on their chronic mismanagement. However it turns out it wasn't like that at all. There was no willful negligence and it wasn't intentionally ignored. There were only two people that knew about the reading, and they deleted it in good faith. They were wrong, but it was at least in good faith as opposed to laziness. I'm still surprised Dan Stessel hasn't blamed this on a customer sneezing in Glenmont.

Despite all the broken fasteners, none of the track walkers noticed this defect either. Can anyone with experience in these tunnels share their opinion on that? I get that it's dark and dingy. It's maybe not something that stick's out like a sore thumb in tunnel conditions. But I'd like to think this is what track walkers are for, therefore they should be trained and properly equipped to notice this stuff.
  by schmod
 
The TGV has also only been in service for a few years.

How would this sort of inspection have been done previously? Focusing on the TGV seems to be distracting from the root cause -- if a clip breaks and the track slips out of alignment, odds are that an awful lot of revenue trains are going to pass over that section of track before the next inspection.
  by JackRussell
 
smallfire85 wrote:
2.Looking at that same Exception report on page 49, you'll notice that two lines above the wide gauge defect is a gauge change defect of 1.5 inches over 26 feet at the same location.This itself is a black condition, and could be very well indicative of poor anchoring of one of the rails. The fact that the number is positive means that the gauge widened 1.5 inches in the direction the TGV was traveling, which was the direction of prevailing traffic (inbound,with the chain marker decreasing). A train traveling in the opposite direction would experience the opposite effect, with the gauge tightening a large amount over a short distance.
OK, I am not quite getting why it would be the case that a train traveling in the opposite direction would experience a gauge tightening. I would have expected a widening, no matter what direction the train was traveling.