Ms. Boyd noted that a sample hazard tracking matrix is located on Page 58 in Chapter 9 of FTA's Implementation Guidelines for 49 CFR Part 659. Detailed recommendations for requiring a hazard management program that complies with 49 CFR Part 659 provisions are included in Section 6 - Hazard Management Process of Appendix E: Program Requirements for Development of a Rail Transit Agency SSPP , located in FTA's Resource Toolkit for State Oversight Agencies Implementing 49 CFR Part 659.

4.  IMPLEMENTING PART 659 HAZARD MANAGEMENT PROGRAM REQUIREMENTS

Mr. Al Fazio, General Manager, New Jersey Transit, River LINE, and Vice President, Bombardier Mass Transit Corporation, facilitated this session, which included four presenters from the rail transit industry, who described their approaches to identifying, resolving, and tracking hazards.

During his introductory comments, Mr. Fazio explained that as a General Manager, he considers an active focus on hazard management to be the best form of "enlightened self interest." Though he acknowledges that other General Managers may not be deeply invested in their agency's system safety programs, Mr. Fazio stated that, for him, in this day and age of 24-hour media and complex relationships with oversight agencies, he could not imagine a situation where he could run his agency and not be actively involved in the implementation of the hazard management program.

Mr. Fazio also explained that, while he is the General Manager of New Jersey Transit River LINE, he is not an employee of New Jersey Transit. Mr. Fazio noted that the operation and maintenance of the River LINE system is managed entirely by Bombardier, under contract to New Jersey Transit. As more and more rail transit service is being provided by contractors, Mr. Fazio explained that there is a movement within the American Public Transportation Association (APTA) to refer to rail transit agencies as "rail transit systems."

Mr. Fazio explained that while this change in terminology may seem insignificant, it is actually quite important because it recognizes that contractors, too, have accountability for critical functions, such as safety, during rail transit operations and maintenance. Therefore, in the APTA Rail Transit Standards Program and other APTA materials, "rail transit system" will be used increasingly more often as a term of the trade.

Mr. Fazio noted that one of the most challenging parts of his job is distinguishing real risk from imaginary risk. For example, he explained that most of River LINE's track runs through suburban areas where there are no threats from overhead construction, and in many cases, no buildings located adjacent to the tracks. River LINE operates Diesel Multiple Units (DMUs) so there are no overhead catenary wires. Therefore, he was actively involved in a hazard assessment which determined that River LINE's track workers did not need to wear hardhats. These workers instead now wear ball caps, which are more comfortable in the field and provide less distraction for workers who must bend over and turn their heads as part of their jobs. By assessing real risk, instead of imagined risks, River LINE was able to ensure safety and to avoid wasting its limited resources enforcing requirements for unnecessary personal protective equipment.

Mr. Fazio also noted that this focus on managing real risks has proved invaluable in working with State and Federal oversight agencies and Conrail to ensure River LINE's access to track on the general railroad system. Mr. Fazio pointed out that River LINE's DMU operate on 34 miles of single track with passing sidings from Camden to Trenton, and a 1.5 mile street-running section of embedded track in Camden. Approximately 24 miles of this alignment is on the general railroad system.

River LINE provides service on this track under the terms of a temporal separation waiver with the Federal Railroad Administration (FRA). To make this work, River LINE uses a combination of advanced rail traffic control, automatic train stop signaling, and temporal separation that yields maximum safety and track availability for passengers and freight. River LINE's operations control center also dispatches ConRail freight traffic at night, Sunday through Friday.

Because of FRA oversight, Mr. Fazio explained that River LINE's operating rules are a Northeast Operating Rules Advisory Committee (NORAC) derivative with additional rules in place for light rail transit operations. However, since River LINE has been waived from some FRA requirements, River LINE also falls under 49 CFR Part 659, and participates in the SSO program managed by New Jersey Department of Transportation (NJDOT).

As a result, River LINE has to work with FRA , FTA and NJDOT to continually demonstrate that running trains at 60 mph over single track with tightly timed meets at sidings, under conditions of temporal separation with freight traffic, is safe. Largely through River LINE's commitment to its program for assessing and controlling hazards, Mr. Fazio noted that River LINE has been able to work with FRA , NJDOT , and Conrail to extend River LINE's service hours and to ensure track access for special events.

Mr. Fazio concluded his comments by stating that it is a very exciting time to be providing light rail passenger service on the general railroad system. Hazard management and appropriate risk identification and mitigation are critical to the success of this service, and to continued dialogue with FRA regarding the possibility, one day, of truly intermingled freight and light rail service on the general railroad system. Mr. Fazio urged anyone who was interested in these topics to consider attending the 14th Railway Age Passenger Trains on Freight Railroads Conference, October 22-23, 2007, in Washington D.C.

a. Internet Based Hazard Tracking Systems

Mr. Fazio then introduced the first speaker in the session, Mr. Henry Hartberg, Senior Manager of Operations Safety, Dallas Area Rapid Transit (DART).

Mr. Hartberg provided a description of DART's automated approach to identifying, assessing, managing, and tracking hazards. Mr. Hartberg noted that DART uses a proprietary, automated Workflow system to manage administrative tasks and that hazard identification and reporting have been incorporated into this system.

Mr. Hartberg pointed out that DART's Workflow system started in the late 1990s as a way to assign, track, and monitor accounts payable items as they moved through the procurement process. However, it quickly became apparent that this system, which enables users throughout the agency to handle and follow-up on workflow actions easily, and which allows supervisors and managers to monitor activities in real-time and to use graphical reports, had wide-spread applicability for a range of DART functions.

Mr. Hartberg explained that, in the beginning, the developers of this system were widely soliciting additional functions and features. Mr. Hartberg met with them and proposed that a hazard identification reporting function be included in the system.

For this function, Mr. Hartberg identified some of the challenges he faced in managing hazards that he believed could be addressed through an automated system:

• Making reporting accessible to everyone, so anyone could log on to the system and electronically file a hazard identification report;
• Enabling the forwarding of reported hazards to supervisors and managers in departments with the authority to assess and resolve the reported hazard;
• Maintaining a transparent record of actions, so it was clear whether action had been taken and what specifically had been done;
• Supporting the integration of the hazard management process at levels of the agency, enabling supervisors and managers to communicate with the Bus Safety Committee (BSC), Rail Safety Committee (RSC), and DART Safety Committee (DSC) regarding hazard reports, assessment and actions, and other activities; and
• Supporting retrieval of records to enhance follow-up, verification, and close-out for hazards.

Further, Mr. Hartberg wanted to make sure that the person filing the hazard report, his or her supervisor, and the DART Safety Department would receive automated emails notifying them of any new activity performed to address the hazard.

Mr. Hartberg also wanted the system to ensure that the hazard identification report was a simple form that the person reporting the hazard could quickly and easily file. Once the hazard identification report was filed, Mr. Hartberg noted that the DART Safety Department would need to use the system to:

• Initiate or delegate requests for action;
• Monitor the status on-going requests;
• Send reminder emails and status update requests;
• Report on actions performed;
• Report on actions not performed;
• Provide real-time follow-up and alerts to the BSC , RSC , and DSC, as appropriate; and
• Ensure that, through the workflow, all involved individuals receive emails advising them of: actions assigned to them, actions they are requested to assign, requests that have been closed, actions overdue or cancelled, and final close-out of the hazard.

Finally, Mr. Hartberg wanted the system to provide the ability, at any time, to check the status of actions performed to address the reported hazard and to provide reports, through scorecards or other features, tracking the time required to close the hazard, the number and types of reported hazards, and the individuals involved.

Mr. Hartberg noted that he was lucky to work with the system developers at the beginning of the process, when DART had not yet fully committed to the Workflow system. The hazard reporting function was only the third or fourth workflow developed, and received a lot of attention and care from the developers.

Now, DART's in-house, web-based, automated task distribution program is greatly in demand, and the developers are back-logged with dozens of requests for new workflows. However, through the strong relationship Mr. Hartberg was able to build with the developers, he was also able to get workflows for DART's random drug testing program and periodic employee physical program. To date, over 60 other workflows are used by DART.

Mr. Hartberg then reviewed screenshots from the hazard reporting Workflow, walking the participants of the 11th Annual SSO Program Meeting through the steps involved. Mr. Hartberg noted the following:

• A Hazard identification report will be submitted either through the Hazard ID Workflow or be submitted to the DART Safety Department for input into the Hazard ID Workflow.
  • Rail and bus operators and maintenance personnel can enter hazards directly into the system through kiosks located in their break rooms or by asking their supervisors to file them on their behalf.
  • Hazards from other sources, such as customer service complaints, or as a result of internal safety audits, rule compliance programs, or accidents or near misses, will be entered into the system by DART Safety personnel.
• Once input, either by the initiators themselves or by DART Safety personnel, the Hazard ID Workflow item will be forwarded to the immediate supervisor who shall investigate the report and initiate a resolution if possible.
  • DART encourages the resolution of hazards at the lowest level possible, and the DART Safety Committee, which is comprised of DART senior management, actively follows up with managers and directors who fail to take action.
• If a supervisor or manager is unable to resolve the hazard, then the supervisor or manager shall forward the Hazard ID form and his or her response to the appropriate Division, Sub-Safety Committee or the DART Bus Safety Committee (BSC), the DART Rail Safety Committee (RSC), or DART Safety Committee (DSC) for review and resolution.
• The decision on where best to forward the Hazard ID will be based on the best judgment of the supervisor/manager.
• The appropriate committee shall review the Hazard ID and initiate a recommendation (if necessary) for resolution whenever feasible.
• If the submitting employee is not satisfied with the response from the supervisor or the RSC / BSC level, the committee shall forward the Hazard ID , along with all recommendations and evaluations, to the DSC for further consideration. The DSC may either accept the recommendations as presented or may initiate their own resolution to the hazard. The DSC decision is final.
• All open Hazard ID forms will be reviewed and updated at all pertinent safety committees on a monthly basis.
• When planning the resolution of an assessed hazard, the actions of the resolving body are guided by DART's hazard resolution guidelines.
• To verify that a proposed resolution has been implemented and has achieved the desired results requires follow-up. Follow-up is the responsibility of both the DSC and the responsible departments using statistical analysis and audits as the primary methods.
• To ensure the on-going role in the oversight of the rail transit agency's hazard management process, DART provides a monthly hazard tracking log that is a function of the Hazard ID Workflow and is organized by hazard identification number. Open hazard I.D.s will be submitted to DART's State Safety Oversight Agency, TxDOT, monthly through the safety committee minutes.
• TxDOT will review the monthly hazard activity and forward any questions or requests for information to the rail agency. TxDOT is sent the minutes of all safety committee meetings once each month after the DART Safety Committee has taken place.
• In addition, DART will conduct meetings with TxDOT upon request and will maintain electronic contact on a regular basis.
• During application of the hazard management process, for any hazard identified as an "unacceptable hazardous condition," the DART Safety Department will notify the TxDOT designated point-of-contact within 24 hours by use of the " TxDOT Notification of a Reportable Accident/Incident, or Hazardous Condition" form. In addition, the appropriate safety committee will conduct an investigation, lead by the DART Safety Department.
• At the conclusion of the investigation, the final investigation report will be provided to TxDOT for review and comment. Any corrective action plans developed as a result of the investigation will be reviewed and approved by TxDOT. The state oversight agency retains the authority to request a status briefing on any unacceptable hazardous condition investigation.

Mr. Hartberg pointed out that, using the system, supervisors and employees can choose different actions from drop down menus, such as "Move to Safety Action Required," which sends the form back to the Safety Department, "Close," "Reject," "Reassign," or "Provide Comments." The "Close" option is only a suggestion to close and requires the Safety Department to review the form and hazard log history before sending it through the Workflow process, which moves the item directly to the DSC for review. Once reviewed by the Committee, the Safety Department can choose "Permanently Close This Item" from the drop down menu, which provides final hazard closure. Any action or reporting tied to the hazard log item is tracked and linked to the item through the "Event History." This creates a complete file for the hazard report.

Mr. Hartberg also informed the participants at the 11th Annual SSO Program Meeting that the DART system is password protected and that only Mr. Hartberg or his designated proxy has the ability to close an item in the system. Mr. Hartberg also has the ability to reassign responsibility resolution activities and provide comments to an item. Mr. Hartberg or his proxy can also initiate emails to the supervisor of the individual responsible for implementing corrective actions instances of inaction.

Mr. Hartberg concluded his presentation by identifying several off-the-shelf software packages that may also be used for hazard management purposes. These included: Intuit Quickbase, Goal Enforcer (Visual), 2020 Software (Internet Based), and Webex.

Identifying and Managing Hazards from the Internal Safety Audit Process

Mr. Craig Macdonald, Director of Risk Management, Claims, and Safety for St. Louis Metro, presented his organization's method for identifying and managing hazards through the internal safety audit process. His presentation addressed Chapters 5, Hazard Management, Chapter 11, Internal Safety Audit Process, Chapter 13, Equipment and Facility Inspections, and Chapter 14 Maintenance Audits of St. Louis Metro's SSPP .

Mr. Macdonald began by providing a brief description of the St. Louis Metro system, which consists of 45 miles of double track, 1 junction and 3 terminal stations; 37 passenger stations; highway-to-rail grade crossings; and 87 Siemens light rail vehicles (LRVs). The system provides 3.5 million miles of service to approximately 24.7 million passengers annually. Mr. Macdonald noted that St. Louis Metro's Risk Management, Claims, and Safety Department is staffed by 21 personnel.

Mr. Macdonald explained that the SSO program for St. Louis Metro actually consists of two SSO agencies - the Missouri Department of Transportation (DOT) and the Illinois St. Clair County Transit District. These agencies have a formal memorandum of understanding and collaborative agreement between them that provides for a single SSO agency program standard. St. Louis Metro coordinates and communicates with both agencies through quarterly meetings and the Executive Safety and Security Committee.

Mr. Macdonald next began a discussion of how his agency identifies, analyzes, and eliminates hazards, pointing out that hazard identification in rail transit systems can be difficult for anyone unfamiliar with these systems. Mr. Macdonald noted that hazards can be identified through the analysis of mishaps or near misses that may occur within the system, reports made by employees or customers, or through the internal safety and security audit review process.

Mr. Macdonald noted that he would be describing how St. Louis Metro identifies hazards through its internal safety audit process. Mr. Macdonald explained that the 21 SSPP and 5 System Security Plan elements, identified in Part 659, are audited over a 3-year period. To assist auditors in completing the audits, St. Louis Metro has developed a 3-year audit schedule, which is included as part of the SSPP . This schedule, provided as Figure 3 below, includes the specific Part 659 reference for each SSPP and System Security Plan area to be audited.

Mr. Macdonald noted that, prior to performing any of its internal audits, St. Louis Metro meets with both officials from both its joint SSO agencies at least 30 days in advance of conducting an audit. Once approved by the SSO agencies, Metro formally schedules the audit.

Topics addressed during the internal safety and security audits include Facility and Equipment Inspections and the Maintenance Audit Process. For Facility and Equipment Inspections, St. Louis Metro audits the LRV inspection program, station inspections, signal houses and traction power sub-stations (TPSSs), and yards and shops. These audits are thorough and includeevaluation of facility components including fire suppression and detection equipment operation, machinery such as cranes, lifts, tools, and personal protective equipment (PPE), material safety data sheets (MSDSs), etc. LRV inspections include doors, track brakes, radius rods, ventilation systems, undercarriage, lights, and emergency systems.

The audits are performed using various standards including the SSPP , NFPA, APTA, SSO Standards, Maintenance Procedures, and Manufacturer Specifications. All findings are documented and verified using written checklists. Mr. Macdonald provided an example of the things that would be reviewed during a facility maintenance audit. These included facility maintenance SOP , housekeeping, emergency evacuation procedures, security and access controls, indoor air quality, and environmental compliance.

During an LRV audit, St. Louis Metro would review maintenance SOP , safety SOP , DOT vehicle inspection criteria, Siemens maintenance specifications, identified safety critical items, best practices, and LRV maintenance records. Mr. Macdonald noted that at St. Louis Metro, LRV inspections are modeled after the DOT and North American Out-of-Service Criteria and all vehicles with Category I defects, as defined below are removed from service.

Category I - Catastrophic: A hazard that may cause death or system loss.

Category II - Critical: A hazard that may cause severe illness injury or major system failure.

Category III - Marginal: A hazard that may cause minor illness/injury or minor system damage.

Category IV - Negligible: A hazard that will not result in injury, illness or system damage.

Audit findings are then prepared by each auditor assigned to perform the audit and are reviewed by the safety manager and affected department. Typical issues identified during these audits include: deficiencies in implementation of the SSPP provisions, standard operating procedures, rulebooks or manufacturer recommendations, improper procedures used in the field (tools, training, schedules), unsafe conditions or procedures in the field (PPE, energized systems), and maintenance deficiencies.

Figure 3: St. Louis Metro Internal Safety and Security Sample Audit Table

Audit Topic 1	Chapter in SSPP 2	FTA Ref. 659	Departments 3	2006	2007	2008
Safety/Security Policy, Goals, Objectives, Mgmt	1,2,4; SSP	659.19(a), (b), &(c); 659.23(a)	SAF; SEC; EXEC. MGMT; ALL			XX
SSPP & SSP Implementation, Review & Approval	3, 20; SSP	659.19(d) & (e); 659.23(e); 659.25	SAF; SEC; EXEC MGMT			XX
Hazard Management	5	659.19(f); 659.31	SAF; OPS; LRVM; MOW; ENGR			XX
System modification & Configuration Mgmt	7	659.19(g) & (p)	SAF; ENG; MOW; OPS		XX
Safety & Security Certification	6; SSP	659.19(h); 659.23(b)	SAF; ENG; RS; SEC; OPS	XX
Safety & security data Acquisition	8; SSP	659.19(i)	SAF; OPS; FROWM; MOW		XX
Accident & Incident Investigation (includes security incidents)	9; SSP	659.19(j); 659.33	SEC; SAF; ALL		XX
Emergency response program	10	659.19(k)	SEC; SAF; OPS; MOW; EXEC. MGMT	XX
Internal Safety & Security Audits	11	659.19(l); 659.23(d); 659.27	SAF; SEC	XX	XX	XX
Rules and procedures compliance	12	659.19(m)	OPS; MOW	XX
Facility & Equip inspections	13	659.19(n)	SAF; MOW; LRVM		XX
Maintenance audits and inspections	14	659.19(o)	LRVM; MOW	XX
Training & Certification & Contractor Safety	15	659.19(p)	OPS; MOW SEC; SAF; CON			XX
Employee Safety & Security	15; SSP	659.19(r); 659.23(c)	SAF; SEC	XX
HazMat/Environmental /MSDS program	17	659.19(s)	SAF; ENG; MOW; PROC		XX
Drug and alcohol testing	20	659.19(t)	HR; MOW; OPS; LRVM; CON			XX
Procurement	19	659.19(u)	PROC; ENG; MOW		XX
Security Threat & Vulnerability	SSP	659.23(b)	SEC	XX
Security Protective Measures	SSP	659.23(c)	SEC	XX

¹ Audit topics for Security & Emergency Management areas may be addressed during the 3-year cycle in cooperation with the TSA B.A.S.E program.
² Refer to SSP for specific security plan references and chapters
³ MOW= Maintenance of Way (includes Facilities & ROW Maintenance and Rail Systems); ENG = Engineering; OPS = MetroLink Operations; LRVM = LRV Maintenance; SEC = Security; SAF = Risk Management & Safety; HR = Human Resources & Benefits; PROC = Procurement; CON = Contractors

As specified in 49 CFR Part 659, corrective action plans, to be reviewed and approved by the SSO agency, are not required for findings or recommendations developed during the internal safety audit process. However, Mr. Macdonald noted that if the internal safety audit uncovers an "unacceptable hazard" then MDOTand St. Clair County do require a corrective action plan. These hazards are reported to the SSO agency verbally within 24 hours and are followed by an initial written report within 7 days. Additional reports are provided to the SSO agency as needed.

The corrective action plan is reviewed and approved by the SSO agency when it is first submitted by Metro, and, again, once it is implemented. The Executive Safety Committee is also notified. This process is described in the SSO agency Program Standard and in Metro's SSPP .

An Internal Safety Audit Process Annual report is developed each year to summarize what audits have been completed and to provide a status of audit item closures for the past two years. The report also describes the audit processes and highlights key findings. Corrective action plans and proposed resolutions are developed or each unacceptable hazard and included in the report. The CEO of St. Louis Metro certifies the report through his signature.

In order to track corrective actions, St. Louis Metro uses a simple database that can export to a summarized format in Excel. The format matches the FTA format used on the 2006 Annual Reporting Template. The CAP Tracker uses electronic and paper distribution systems to provide applicable parties with necessary corrective action plan data such as responsibilities for closure and status. Corrective action plans are reviewed at quarterly meetings and at Executive Safety and Security Committee meetings.

Identifying and Managing Hazards during Operations

Ms. Theresa Impastato, Safety Manager, New Jersey Transit (NJT), South New Jersey Light Rail, River LINE, presented NJT 's methods for identifying and managing hazards duringoperations. She began her presentation with a brief description of the River LINE, building on the overview provided by Mr. Fazio. River LINE uses Diesel Multiple Units (DMUs) to operate on 34 miles of track from Camden to Trenton, including a 1.5 mile street running section ofembedded track in Camden, NJ. River LINE operates on the general railroad system under atemporal separation waiver from FRA . ConRail freight traffic is dispatched by the River LINE control center staff at night, Sunday through Friday. Ms. Impastato explained, as noted by Mr. Fazio, River LINE is under the duel regulation of FRA and FTA, with State Safety Oversight provided by New Jersey Department of Transportation (NJDOT).

Ms. Impastato next began her discussion of NJT 's hazard identification and resolution process during operations and maintenance, stating that this process is essential to the continued safety of the system. The methods for identifying hazards within NJT 's operations and maintenance include clear communications (with control center, through communication links, work orders, and committee meetings); inspections of vehicles, facilities, and the alignment; audits of safety critical systems; review of maintenance records; and through acceptance testing. The hazard classification and management system used by the River LINE conforms to MIL-STD-882 requirements for severity and probability.

In compliance with Federal requirements and in addition to State standards, the River LINE reports hazardous conditions to the appropriate regulatory agencies including the FRA and NJDOT and, under certain conditions, will meet with NJDOT to devise a mitigation strategy and execution plan. In order to ensure the continued monitoring of the resolution of hazardous conditions, a monthly update on the River LINE's actions is sent to the SSO agency.

Quarterly hazard management meetings are also held by NJDOT , in which each railroad under their oversight presents an update on the progress of their hazard resolution actions. These meetings enable all operating entities under State Safety Oversight to share information, evaluate best practices and engage in discussion and review of current events. Quarterly updates are also sent to FRA on the progress associated with reportable conditions.

Internally, hazardous conditions are tracked via an Access database with monthly reports being made available to the SSO agency. During the monthly System Safety Committee meetings, open items are tracked in the meeting minutes and reviewed for action. Daily management meetings are held in the mornings, which also track the progress being made on open action items. Monthly management meetings are also held, during which time, more in depth tracking of actions takes place. Hazardous conditions are analyzed and evaluated to determine root and contributory causal factors. Based on the root cause findings, mitigation will include a combination of procedural, operational, and mechanical changes in practice.

Ms. Impastato explained that the River LINE has sought to actively identify, mitigate, and document hazardous conditions during operations. She then provided two examples, involving (1) human factors and (2) system integration deficiencies. The first example involved stop signal violations, which are typically caused by an operating rule violation in which the LRV operator fails to properly acknowledge a restrictive or approach signal indication and proceeds past the upcoming stop signal. The second example involved loss of shunt (LOS) incidents, which are caused by the failure of the light rail vehicle (LRV) to properly occupy a track circuit resulting in the potential for the signaling system to display a "false" proceed indication.

To address the first example, Ms. Impastato provided greater detail regarding the River LINE's signaling systems. The River LINE is a single track railroad with passing sidings that employ a Northeast Operating Rules Advisory Committee (NORAC) compliant wayside signal system designed for a freight braking profile. The use of a fixed light rail transit (LRT) approach sign indicates to an LRV operator the braking distance to the signal. The signal system includes automatic train protection (ATP) in the form of trip stop inductors used to arrest the motion of a vehicle passing a stop signal through a penalty application of the emergency braking system.

Ms. Impastato noted that River LINE experienced a series of stop signal violations which exceeded the industry average occurring over a three year period. As a result, NJT performed an analysis of the signal violation conditions to determine root causes and to verify any suspected statistical relationships. Initially, a number of factors were thought to be causing the signal violations. These included the location of the violation, direction of travel, length of time in service, time of day, weather conditions and visibility, and fatigue. While certainly contributing to the probability stop signal violations, none of these causal factors showed a statistically significant relation to the probability of a signal violation occurring.

NJT next interviewed operators to determine if there was a common thread between the signal violation incidents. The vast majority of the LRV operators who had violated a stop signal stated that they had observed the approach signal indicating that they were to approach the next signal prepared to stop and upon seeing an opposing movement clear their consist, presumed that the signal was permissive for their movement. Ms. Impastato pointed out that this turned out to be one of the most significant findings in addressing the signal violations as distraction and complacency require different methods of mitigation than presumption.

To mitigate the hazardous condition, a white paper was first written on the River LINE's stop signal violation reduction program, focusing on the reduction of violations through operational and procedural means. This was done because the violations were related to human factors.

Additionally, when a stop signal is passed the trip stop inductor activates the LRV emergency braking system stopping the LRV prior to the fouling point of any switch. The opposing interlocking signals are immediately set to stop with active trip stop inductors to stop any train from entering the fouled interlocking. The central control system receives a "passed stop signal" alarm indicating to the dispatchers that all permissive signals have dropped and all train traffic in the area has stopped

Also, the disciplinary policy was reviewed and minor revisions were made creating a progressive policy to address repeat offenses. Investigation procedures were also reviewed with emphasis on improved root cause determination of signal violations; and post-incident review requirements were established for operator retraining.

NJT also implemented a number of operational mitigations. Operators were instructed to announce any restricting or approach signal indications received over the radio. This was required to enhance the operator's situational awareness via a verbal reminder of upcoming conditions. The Rules and Procedures Efficiency Checks program was reviewed. Increased check rides and banner obstruction tests were performed along with reverse routing practices employed at random to alter the signal indications received in the field. Random LRV downloads are taken daily and reviewed by the Safety Department and Trainmasters to evaluate operator compliance with rules and restrictions. When a pattern of non-compliance is observed, the operator is subject to re-training and increased frequency of ride checks in order to establish proper habits in the operator.

Systemic changes include a bi-weekly signal preview ride in which the Signal Maintenance Supervisor is required to make a round trip check ride to ensure that all signals have acceptance previews. Also, LRT approach signs were enlarged.

Potential long-term mitigations include the installation of a cab-signaling system for the River LINE, in which operating speeds are enforced via an indication in the operators cab and penalty braking applications. While a cab-signaling system will not eliminate the potential for a signal violation, it will reduce the severity of a violation markedly via the enforcement of operating speed.

After the implementation of these mitigation actions, the River LINE has observed a 78% reduction in signal violations.

Ms. Impastato next gave further details regarding the loss of shunt incidents the River LINE began experiencing in the fall of 2005. The cause of these incidents was believed to be excessive leaf build-up on the rail and subsequently on the LRV wheels. In response to this condition, the River LINE implemented several operational mitigations. First, the Central Control System alarms alert controllers via a "Loss of Indication" alarm when an interruption in the track circuit occurs. Upon receiving the alarm, the control center applies blocking devices to the interlocking signals and switches and instructs all trains to report clear of the CP in question, further increasing the margin of safety incurred via the "clear block" operating practice.

Maintenance mitigations included dispatching signal maintainers to the field to verify the alarm concurrently with the operational mitigations taking place. Field conditions are documented. Vehicle maintenance crews also inspected the LRVs that lost indication and noted any abnormal wheel conditions.

In order to effectively mitigate the hazardous condition created by a Loss of Shunt or LOS Incident, River LINE first needed to determine the causal factors contributing to the occurrence of these incidents. This began with an extensive statistical analysis of the incidents. Twentyeight LOS incidents occurred on the River LINE alignment during the period from November 1, 2005 through November 14, 2005. Variables analyzed to determine if there was a significant statistical relationship between their values and the probability of a LOS incident occurring included direction of travel, length of time elapsed since last LRV wheel truing, location, scrubbing activity by location, ConRail movement by location, weather conditions, length of track circuit, time of day, LRV consists, and interlocking and ABS territory.

Due to the short time frame of data available, all common causes of variation may not have been introduced into the sample in proportion to their relative size in the population. The small sample size may have introduced a minor bias into the data.

• α risk was tolerated within the 0.05 - 0.10 range resulting in 95 % to 90% accuracy in preventing a Type I error, or assuming an error was made when one was not.
• β risk was tolerated in the 0.10-0.20 range resulting in 90% to 80% accuracy in preventing a Type II error, or assuming no error was made when in fact, an error occurred.
• A sample size greater than 60 has been calculated to produce optimum results.

Four variables including weather, time of day, location, and length of track circuit exhibited a statistically significant relationship to the probability of experiencing a LOS incident. These four variables were further analyzed using multiple regression analysis to determine their interactions and to examine any spurious correlations which may have existed. Through this analysis, it was determined that time of day and weather appeared to be strongly correlated, but are not statistically independent.

After confirming the causal factors statistically, the next step was to look at reducing the probability of a LOS incident occurring by focusing efforts on the reduction of the effects of each variable. Since controlling the weather or leaf drop was not feasible, the River LINE sought to control the influence of these factors. A three pronged approach was taken to address the condition focusing on integration of the track conditions, the signal system, and the vehicle system.

In order to control, to the fullest extent possible, the environmental conditions which contribute to the probability of experiencing a LOS incident, the River LINE has undertaken an extensive vegetation control program. This program includes brush cutting and pre- and post-emergent weed spraying concentrating on the areas where a loss of shunt incident occurred.

Signal system mitigations included increasing LOS timing in other areas. A modification to the LOS timing in CP 242 and CP 269, both problem areas, was completed in 2006. Increasing the LOS timing in these areas has proven to be effective at reducing the number of shunting incidents experienced in 2006. Comparison between sample populations of LOS incidents experienced in 2005 and 2006 showed a 40% reduction in the test areas with increased LOS timing. Based on the success obtained in reduction of LOS incidents within the pilot area versus the remainder of the alignment, an increase to 15 seconds of LOS timing was implemented system-wide in January 2007. NJT also split long (over 5000 ft) track circuits into multiple circuits. This work is expected to be completed during the fall of 2007, and should also mitigate LOS issues experienced during rainfall.

Track condition mitigations included an "Aqua Train" and profile grinding of the rail. The Aqua Train is a high powered water jet system used by NJT to clean contamination from the rails. The train is currently being evaluated for use on the River LINE. Research has been conducted on similar consists across the US, and a tank car and a flat car have been procured for use as an aqua train on the River LINE.

Profile grinding of the rail to modify the wheel/rail contact patch in order to improve shunting capabilities is being evaluated for a system-wide application excluding the street running sections of track. Two wayside shunt enhancers were also procured for installation in problem track circuit areas in 2006. Installation on track circuit 2541 was completed feeding both directions. Monitoring of the enhancer's performance has taken place with two private crossings which pose no hazard to vehicular traffic if the crossing system malfunctions. Initial results appear to improve shunting capabilities and additional units have been installed in identified problem areas. Further evaluation of the effectiveness of these mitigations will occur during the fall of 2007.

Cast iron wheel shoes were designed to eliminate the contaminant build-up on the LRV wheel sets. Stainless steel and composite material shoes were also evaluated. Cast iron was considered to be the preferred material due both to its longer wearing qualities and its ability to "rough" up the wheels allowing the wheel to bite through the leaf matter on contaminated rails. Tests of the wheel shoe effectiveness were conducted with significant improvements to shunt capabilities in adverse conditions noted. Third generation wheel shoes will be evaluated during the fall 2007.

A peer review consisting of representatives from railroads who have experience in shunting and adhesion problems will also take place in October of 2007, and continued information sharing is taking place between the River LINE and other systems world-wide with regard to leaf contamination.

Ms. Impastato explained that since the River LINE does not experience LOS Incidents outside of the fall season, each change made during the preceding year is carefully tracked and evaluated for its impact on the shunting capabilities of the system.

d. Approaches for Evaluating Hazard in the Rail Transit Environment

Mr. Nagal Shashidhara, Director of System Safety and Quality Assurance Program for Light Rail Operations, New Jersey Transit gave a presentation outlining challenges experienced by rail transit agencies who use Military Standard 882 D (or earlier versions) in guiding their hazard assessment activities. Mr. Shashidhara noted that he is frequently frustrated when applying MIL-STD 882 in the rail transit environment, because the standard was designed to support space travel and advanced weapons systems.

Mr. Shashidhara explained that in MIL-STD 882, a single fatality is a catastrophic event. Mr. Shashidhara noted, much to the collective amusement of participants at the 11th Annual SSO Program Meeting, that there are no grade crossings in space. Also, there are no trespassers or suicides or automobile drivers making illegal left turns in space.

Yet in transportation, there are approximately 45,000 annual fatalities on our roadways, and the rail transit industry experiences 60 to 80 fatalities each year. Managing risk, even from fatalities, is a critical part of what rail transit agencies do. However, since MIL-STD 882 is based on an extremely high standard, more suitable to the National Aeronautics and Space Administration (NASA), application of this matrix in the rail transit environment tends to encourage overly restrictive requirements that do not contribute to overall safety and, that sometimes, lead to impractical conclusions.

In assessing and resolving risk, Mr. Shashidhara noted that the three light rail transit agencies in New Jersey have a variety of processes they use to identify, evaluate, and control hazardous conditions. Acceptable risks are determined through engineering means, combined with education, training, enforcement and disciplinary actions.

Mr. Shashidhara expressed his opinion that much of risk management in the rail transit industry ultimately centers on creating conditions that lead the public, customers, and transit operating staff to appropriate behavior. Mr. Shashidhara emphasized that experience in transit system safety, local environmental settings, and actual data should play a key role in assessing hazards. He further explained that in the operation of a transit system, there are many situations that may result in an unwanted event and that transit systems should implement programs to avoid such events, even though doing so may require the system to take a chance at achieving an operational gain versus some future, low probability, potential loss.

Mr. Shashidhara next reviewed the consequences of ignoring risks, by first defining risk as the potential for the realization of unwanted, negative consequences of an event. He explained that risk reduction involves avoidance of losses and the unwanted consequences as well as the probability and potential for such losses. These losses can take financial, human, legal, and other forms such as diminished public confidence in the system or environmental impacts.

While there may be some general agreement in the rail transit industry on the importance of resolving "unacceptable" hazards, many rail transit agencies spend most of their time focusing on "undesirable" hazards. For these hazards, the risk can be tolerated if it can be demonstrated to be as low as reasonably practicable, following senior management review. Therefore, while potentially serious, these events do not necessarily justify the expenditure of resources for their remediation. Examples of undesirable hazards or risks provided by Mr. Shashidhara included:

• Auto crashes through crossing gate and collides with train
• Trespasser enters ROW , contacts third rail
• Auto stalls on tracks, train collides with auto
• Auto ignores traffic control device and collides with train
• Passenger falls into trackway and is struck by train entering station
• Trespasser enters ROW
• Auto drives around crossing gate
• Red Signal (Stop Signal)Violations
• Lockout/Tagout violations
• Derailments
• Speeding Violations
• Improper De-Energization or Re-Energization
• Entering Out-of Service Trackage (Failure to properly post out-of-service limits signage)
• Blue Signal Violations
• Unauthorized use of a block

Also, Mr. Shashidhara pointed out that rail transit agencies must assess the impacts of other undesirable events on risk, such as the following:

• Tardiness
• Absenteeism
• Insubordination
• Leaving the property without authorization
• Driver Abstract Review
• D&A Policy-Failure to Provide Sample
• Rules Related-Non Safety
• Intentional Damage to Property

In applying the MIL-STD-882 matrix to these events, rail transit agencies receive little more than confirmation that the risks, are in fact, "undesirable." However, the MIL-STD 882 matrix does not provide sufficient detail regarding what a rail transit agency should do - if anything - to prioritize or mitigate these risks. It does not help safety managers indicate where additional resources should be applied.

Mr. Shashidhara then reviewed other models in use in this country and abroad that expand the basic MIL-STD-882 precepts to include other elements, such as "hazard detectability" and "operational impacts." Hazard detectability is a measure of the ability to adequately detect, notice, and communicate an unsafe condition or action. Operational impact addresses potential interruption of service as a result of the event. By adding these two features to the basic MIL-STD 882 matrix, the resulting Risk Criticality Number (RCN) provides a relative scale of priority. Mr. Shashidhara noted that by using this approach, hazard severity can measured according to the following scale:

Hazard probability can be measured as follows:

Hazard detectability can be measured as follows:

Operational impact can be measured as follows

Using these measures, Mr. Shashidhara noted that the worst possible combination would consist of a Severity of IM (most severe), a Frequency of A (most frequent), a Detectability of Da (not detectable), and an Operational Impact of Ola (most severe).

Another model, used in India, expands this approach even further. Following this model, hazard frequency classifications are determined using the following:

Safety Severity categories include:

Reliability measures include:

Frequency, safety severity, and reliability are then combined to generate the following Risk Criticality Matrix:

Each risk classification is defined as follows:

Mr. Shashidhara noted that both of these approaches offer clear advantages for the rail transit industry over the MIL-STD-882 matrix. Mr. Shashidhara recommended that FTA work with the SSO agencies, the rail transit industry, and APTA to review the current MIL-STD 882 matrix to determine if a new, more applicable model should be included in 49 CFR Part 659.

Mr. Shashidhara recommended the formation of a Task Force to review these issues in greater detail. Mr. Shashidhara noted that judicious application of the risk analysis process for rail transit operations must consider all of the above mentioned factors. Using these factors, a revised matrix may be developed to allow for greater flexibility in transit operations.

e. Hazard Management Team Building Exercises

During the Monday afternoon session of the 11th Annual SSO Meeting, the attendees broke up into two groups. Each group was given three hazard scenarios to evaluate and discuss. The scenarios included:

• Scenario 1: On the evening of July 3, 2007, a construction project is nearing completion alongside an active portion of a rail transit system's right-of-way. This section of the alignment is single-tracked and the project involves the excavation and replacement of a portion of a nearby drainage pipe. The work crew, which is being overseen by the transit agency's Resident Engineer, is concluding the day's activities. Meanwhile, rush hour has just begun and the system is experiencing higher than normal ridership due to the July 4th holiday. Before leaving the site, two members of the construction crew, in a rush to get home and in an attempt to save time, place a 150 pound, low profile, piece of equipment in what they feel is an indiscrete, yet safe location, next to the track. The equipment is within 4 feet of the active right-of-way and goes unnoticed by the Resident Engineer and the remainder of the crew. The first train operator to travel through this section of track notices the equipment and reports it to the control center. The control center reports the equipment to the maintenance division, but due to the larger than normal ridership demands of the day and the need to remain on schedule, the maintenance division does not plan to dispatch a track crew to remove the equipment until after evening peak service concludes.
• Scenario 2: After years of service, a section of track belonging to a busy rail transit system has started to degrade. The rail transit agency has been aware of the problem for quite some time, but due to a lack of resources and a need to meet increasingly heavy ridership demands, the agency has not been able to fully upgrade and repair this section of track. As a result, the track condition in this area is very poor, the ballast is heavily contaminated, and there is little drainage in the area. Over the past two weeks, the control center has been receiving false indications from this section of track and a maintenance crew has been dispatched to identify and correct any problems that may exist. After performing a thorough inspection of the track area, the crew identifies a 27 inch horizontal crack between the head and web of a piece of rail. The crew reports the crack and takes steps to replace the affected piece of rail.
• Scenario 3: At a Board Meeting on the budget, the Director of the Engineering at a rail transit agency gives a report entitled "A Prediction of the Rate of Stray Current Corrosion of Rail Fasteners." The Director of Engineering has prepared this report to support his request for additional funding of maintenance activities. This report notes that if the transit agency's request for additional maintenance funds is not met, then his department will not be able to stem water seepage into tunnels; to replace rail fasteners, rail ties, and tie plates; and to replace insulators. If his department cannot perform these activities now, then there is a significant probability that rates of corrosion may increase exponentially on two heavily-used rail transit lines over the next year. The Director of Engineering further explains that he does not have sufficient personnel in his staff to keep up with the maintenance demands likely to result from the increased rate of corrosion. He ends his presentation by urging the Board to approve his budget request. The Board thanks him for his presentation, and takes his recommendations under advisement. However, due to a city-wide budget crisis, the Board does not approve the request.

For each scenario, each group was asked to consider several questions:

• Did the condition described in the scenario constitute a hazard
• How would the condition described in the scenario be reported to the rail transit safety function?
• How would the condition in the scenario be evaluated by the rail transit safety function?
• Should the condition in the scenario be reported to the SSO agency?
• What specific steps would your agency take to manage the condition in the scenario?
• What corrective actions would be taken by your agencies in response to this situation?
• How would your agencies track such an occurrence?
• When would it be considered closed-out or resolved?

After each group evaluated their respective scenarios, the attendees reconvened to report back their findings and conclusions. In general, each group determined that the scenarios were not "unacceptable hazardous conditions" and, as such, did not have to be reported to the SSO agencies. However, each scenario required actions to be taken, and if left unaddressed, could potentially result in an accident.

Meeting participants voiced their appreciation for the hazard management exercises, stating that the exercises helped States and transit agency representatives to address confusion surrounding the hazard management process and observe and discuss the varied approaches implemented throughout the industry. FTA appreciates the feedback from participants and will develop similar group exercises for future meetings and workshops.

DAY TWO, TUESDAY, SEPTEMBER 18, 2007

5.  FINDINGS AND RECOMMENDATIONS FROM THE NTSB INVESTIGATION INTO THE JULY 11, 2006 DERAILMENT AT THE CHICAGO TRANSIT AUTHORITY

On Tuesday, September 11, 2007, NTSB conducted a public hearing regarding its 14-month investigation into the July 11, 2006 derailment on the Chicago Transit Authority (CTA) Dearborn Blue Line subway. As a result of its investigation, NTSB determined that a deficient safety culture existed at CTA that allowed the track infrastructure to deteriorate to an unsafe condition.

NTSB also determined that CTA's State oversight agency, the Illinois Regional Transportation Authority (RTA) and FTA, through its oversight of Illinois RTA, failed to require CTA to develop corrective actions to address identified safety deficiencies. Specifically for the CTA derailment, NTSB identified concerns with:

• The quality of the track inspection and maintenance program developed by CTA and documented in the CTA System Safety Program Plan (SSPP), including the organization of roles and responsibilities; the quality of the referenced track standards; the training, qualification, and evaluation of track inspectors; the staffing of CTA's track inspection and maintenance department; and the scheduling of track inspection and maintenance activities.
• The level and quality of verification performed by CTA's system safety department in assessing CTA's implementation of its track inspection and maintenance program, as specified in CTA's SSPP , during its 2005 internal safety audit.
• The level and quality of verification performed by Illinois RTA during its 2004 Three-Year Review at CTA to assess CTA's implementation of its SSPP , and the failure of Illinois RTA to require corrective action plans for track deficiencies identified during a "field observation" conducted as part of the review.
• The level of oversight provided by FTA, including FTA's failure to require Illinois RTA to demand corrective actions for track deficiencies identified as part of its 2004 Three-Year Review.

NTSB adopted recommendations for CTA, Illinois RTA and FTA. During the hearing, NTSB stated its opinion that implementation of these recommendations would strengthen the SSO program and its implementation at CTA and all other rail transit agencies affected by 49 CFR Part 659.

a. Overview of NTSB Investigation Process and Findings

Ms. Annabelle Boyd, FTA SSO program contractor, provided an in-depth presentation regarding NTSB's findings and recommendations. Ms. Boyd began with a description of the CTA derailment.

On Tuesday, July 11, 2006 at a little after 5:00 p.m. the operator of CTA train number 220, an 8-car train traveling northbound in the CTA Blue Line subway, received a "blue light alarm" on his control panel, indicating a problem with one of the cars. The train had operated normally through Clark/Lake Station and was proceeding toward Grand/Milwaukee station. The "blue light" operated in conjunction with an exterior indicator that illuminated both sides of the problem car.

The operator stopped the train, and looked back through his window to determine which car was having problems. He was unable to see the external indicator light due to track curvature and limited visibility. The operator decided to address the problem at the next station, and proceeded forward. As the train began to move, its emergency-braking mode automatically activated and brought the train to a stop.

The last car of train number 220 had derailed in a slight curve to the left approximately 53 feet past Clark/Lake Station. The point of derailment, later identified by NTSB, was the approximate location where the train was when the "blue light" warning activated.

At the point of derailment, an electric arc caused material under the train to catch fire. Thick smoke began to fill the tunnel. The front of the train was now located approximately 350 feet from the emergency exit grate at Clinton and Fulton.

The train operator immediately contacted CTA's Control Center and requested that power be removed. The train operator then exited the train and walked along the catwalk to investigate. Many passengers had self-evacuated from the rear of the train and were walking toward him, reporting smoke and fire. The train operator used his voice and hand signals to direct more than 1,000 passengers away from the smoke to the emergency exit grate at Clinton and Fulton. The train operator also checked each car to make sure that the passengers were evacuating.

Ms. Boyd noted that the evacuation took a little less than an hour. The Chicago Fire Department, which assisted in the evacuation, reported that 152 persons were treated for injuries, mostly related to smoke inhalation. There were no fatalities. Total damage to the derailed CTA vehicle and track exceeded $1 million.

Ms. Boyd then described the NTSB response to the derailment. After being notified, NTSB immediately dispatched a 12-member investigation team to CTA. During the course of its on-site investigation, NTSB:

• Interviewed the train operator and reviewed his personnel records, training records, hours of service records, and drug and alcohol test results,
• Interviewed passengers, witnesses, and emergency responders,
• Conducted an extensive examination of the derailment site,
• Collected samples from damaged rail equipment, track, ties, and fasteners, and sent them to their lab for analysis,
• Requested and reviewed CTA track inspection records for the past 12 months,
• Observed a track inspection on the territory including the derailment area,
• Conducted interviews with track walkers and maintenance personnel, and CTA personnel knowledgeable in traction power and ventilation systems,
• Tested the signal system and reviewed signal data, and
• Conducted interviews with State safety oversight agency personnel at the Illinois Regional Transportation Authority (RTA).

NTSB also conducted a three-hour interview with FTA on November 28, 2006 to discuss the SSO program and FTA's oversight of the Illinois RTA. NTSB was represented by Mr. James Southworth, Director, NTSB Railroad Division; Mr. James Henderson, Investigator-in-Charge of the CTA derailment; and Mr. Robert Campbell, Railroad Investigator on the CTA derailment.

FTA was represented by Mr. Scott Biehl and Mr. Richard Wong from FTA's Office of Chief Counsel (TCC); Mr. Ronald Hynes from FTA's Office of Research, Demonstration and Innovation (TRI), and Mr. Michael Taborn from FTA's Office of Safety and Security (TPM-30). FTA Administrator James Simpson and Mr. Richard Steinmann, Senior Advisor to the Administrator, were also in attendance.

During the meeting, FTA reviewed its enabling legislation and the approach FTA used in developing 49 CFR Part 659. FTA also answered a number of questions from the NTSB investigators regarding:

• Existing track inspection standards and procedures in the rail transit industry,
• 49 CFR Part 659 requirements related to maintenance,
• Existing approaches used in the rail transit industry for training rail maintenance personnel,
• Existing qualifications of rail transit track inspectors and supervisors, and
• Qualifications of rail transit safety personnel and SSO personnel to perform track inspections.

Ms. Boyd then turned to the September 11, 2007 NTSB hearing. Ms. Boyd noted that NTSB determined that the probable cause of the derailment was:

"The Chicago Transit Authority's ineffective management and oversight of its track inspection and maintenance program and its system safety program resulted in unsafe track conditions."

In making this finding, for the first time, NTSB cited the system safety program managed by a rail transit agency part of the probable cause of an accident it investigated.

NTSB also determined that contributing the derailment were:

"The Illinois Regional Transportation Authority's failure to require that action be taken by the Chicago Transit Authority to correct unsafe track conditions, and the Federal Transit Administration's ineffective oversight of the Regional Transportation Authority."

With this determination, for the first time since 49 CFR Part 659 went into effect in 1997, the NTSB cited the inaction of an SSO agency as a contributing factor for a rail transit agency accident. Further, this is the first time ever that NTSB has cited FTA's oversight of an SSO agency as a contributing factor to an accident it investigated.

NTSB Rationale

Ms. Boyd then reviewed NTSB's rationale in making these findings of probable cause and contributing factors. Ms. Boyd noted that NTSB determined that this derailment was an "organizational accident," resulting from systemic failures at every level within CTA, Illinois RTA, and FTA.

NTSB determined that CTA had adopted a flawed track inspection process, where track inspection and maintenance were performed by the same individuals. Track inspectors worked Monday to Friday, 7:00am to 3:00pm. They inspected track on Mondays and Thursdays. On Tuesdays and Fridays, they made minor repairs to the defects they had identified during inspections. On Wednesdays, they worked as part of maintenance crews to address larger defective track conditions.

During the hearing, NTSB investigators questioned why CTA would structure this organization so that inspectors would be responsible for identifying repairs that they would then have to make. NTSB believed that this organization was poorly designed, and limited the integrity of the track inspection process.

NTSB also expressed concerns about the track inspection process itself. When walking track, inspectors had to confirm that the optimal gage of 56 and ½ inches was in place to sustain train speeds of 25 mph. The allowable speed for track gage equal to 58 inches was 6 mph. If inspectors identified track gage beyond 58 inches, the track should be removed from service.

In managing these inspections, track inspectors were equipped with a flashlight, a tapeline ruler or a carpenter's fold-out ruler, chalk, a pen, and a note pad. NTSB also noted that no gage templates or automated inspection devices were used, and that lighting in the subway tunnels was poor. Locations of needed repairs were marked in tunnel walls and rail with chalk and written on note cards, for later transcription to the inspection reports. However, track inspectors left the tracks at 2:45pm, each day, leaving little time for documentation on the day in which the inspection was conducted.

NTSB noted that there were missing inspection records. In fact, more than 80 percent of inspection records were missing for the Blue Line territory where the derailment occurred between May 1 and July 11, 2006. A 12-month expanded review of all track inspection records showed:

• Hundreds of inspection records were not available
• No territory had met CTA's required two inspections a week
• Large periods of time with no inspection records
• Many were not filled out correctly
• Many records identified defects, but not the repairs
• Defects concentrated in certain areas

NTSB also found that there was insufficient inspection time provided. NTSB observed a "typical day" of track inspection in the Blue Line territory where the derailment occurred. In this case, the inspection territory was 6.22 miles long - 3.11 miles in each direction. Inspectors entered the track at 9:00am when train headways were reduced to 7 minutes, and left by 2:45pm. There was no weekend, nighttime, or overtime track inspection scheduled. Inspectors walked track, but faced constant distractions from oncoming trains and the need to clear. Perhaps 4 of every 7 minutes could be spent on track inspection. During the "typical inspection" observed by NTSB, the inspector was unable to complete the assigned inspection. He was about 1.5 miles short. However, the inspection report was completed for entire territory.

NTSB also concluded that CTA failed to provide an adequate number of personnel to perform inspections. CTA only had 2 inspectors per territory. There were no back-ups or "floating" personnel. In the event of the absence of one of the inspectors, due to illness, vacation, holidays, or other reasons, inspections could not take place. NTSB also determined that maintenance took priority over inspection, and that inspections would be halted and inspection personnel would be utilized to make priority repairs on Mondays and Thursdays. Finally, NTSB observed that, while CTA management expected inspections to get done, they provided no additional time for track inspectors to walk track and made no allowances for over-time.

NTSB also observed the limited training and qualifications for CTA track inspectors. NTSB noted that these inspectors were required to have one year of construction experience and one day of classroom training on CTA's Track Maintenance Standards Manual. While this training did cover the 16 possible indications of a gage problem, including dark streaks on the inside rail of a curve, lateral movement of a tie plate on the tie or rail on the tie plate, missing spikes, and poor tie conditions, the training did not cover special issues associated with conducting inspections in tunnels or on elevated structures, or problems associated with electrolysis and corrosion. NTSB noted that inspectors they interviewed stated that this training covered too much material in one day, and was difficult to implement in the field.

After completing the one-day training course, CTA inspectors then went through one year of on-the-job training, where they worked with a more senior inspector. There were no qualification exams, refresher training, or formal performance evaluations provided by senior management. NTSB found that even these minimal requirements has not been met, and there was wide-spread evidence of inexpert and inappropriate repairs on the track.

Finally, NTSB found that CTA, which relied solely on the visual inspection of its track, failed to use technology advancements, such as track geometry vehicles and rail defect detector vehicles, to ensure track integrity. NTSB also expressed its opinion that CTA's track standards were incomplete because they did require rail flaw detection or track geometry inspection, and did not include rail fastener requirements and corroded rail requirements.

NTSB determined that:

"The dark area on the inner rail of the curve, the abrasion on the tie plates and ties, the broken lag screws, and the tie plates' elongated fastener holes in the area of the derailment were all readily observable and should have been documented during walking inspections."

NTSB found that because CTA "failed to establish an effective track inspection and maintenance program, unsafe track conditions and deficiencies were not corrected."

Missed Opportunities in Safety Oversight

Based on its investigation, NTSB also determined that there were a series of failures in the safety oversight process that should have identified the deficient track conditions and required corrective action, but did not. NTSB referred to these failures as "missed opportunities."

Ms. Boyd then briefly reviewed each of these "missed opportunities" identified by NTSB.

Missed Opportunity #1: 2004 APTA Safety Review

An APTA Rail Safety Review was conducted at CTA in 2004. This review made two findings on track inspection:

• Track geometry vehicle inspections were needed. APTA noted that CTA was seeking sources of funding for this project.
• System Safety and Facility Maintenance personnel must meet specific training and education requirements.

While the APTA Review was voluntary, corrective actions were not developed, followed up, and resolved by CTA.

Missed Opportunity #2: 2005 CTA Internal Safety Audit Process (ISAP)

During its 2005 ISAP of track inspection and maintenance, CTA's system safety officers and engineers:

• Were not trained in how to conduct track inspections.
• Had no authority to review track inspection reports.
• Had no authority to observe the performance of track inspection.

During its 2005 ISAP, CTA's system safety officers reviewed implementation of CTA's SSPP requirements with senior management in the maintenance function, and received assurances and reports showing that the specified inspection activities and corresponding oversight were being performed as documented in the SSPP .

In its 2005 ISAP, CTA's system safety officers made no findings regarding the performance of track inspection and maintenance. NTSB found this approach to be highly inadequate, and determined that CTA's safety function needed additional authority to oversee implementation of the SSPP provisions related to track inspection.

Missed Opportunity #3: 2004 Illinois RTA Three-Year Safety Review

As part of its 2004 Three-Year Safety Review, Illinois RTA conducted a "field observation" of the CTA track and stations. Illinois RTA observed the following conditions:

• Skewed and twisted track plates;
• Deteriorated half-ties and areas of mud and excessive water on the track structure on the Red and Blue lines; and
• Large number of gage rods indicating potential track fixation issues on the Red line.

It should be noted that none of these conditions were observed in the area where the derailment occurred, and that this "field observation" was conducted from CTA station platforms.

Illinois RTA also noted that there were fewer track inspection personnel at CTA when compared to other similar transit systems, and less formal training of track inspection personnel at CTA than is typically provided in the industry.

Based on these observations, Illinois RTA reviewed CTA's annual Capital Improvement Plan, and noted that approximately 4,000 tie replacements were scheduled for both the Blue and Red Lines, and that grouting initiatives were underway in the Blue Line and the Red Line tunnels to stem water seepage. Further, Illinois RTA determined that, in 2004, CTA was implementing its scheduled maintenance program. Also, Illinois RTA determined that:

• In 2004, evidence was available that CTA inspectors were observing track defects and comparing them with the rating categories established in CTA's Track Maintenance Standards Manual for the various posted speeds.
• Most of the documentation reviewed demonstrated, in 2004, a track inspection program in general compliance with CTA's SSPP and supporting procedures.
• Further, interviews conducted at CTA also supported this position.

As specified in FTA's Part 659, Illinois RTA issued findings requiring corrective action only on whether CTA was implementing the track maintenance section of its SSPP and whether this section needed to be updated. Since CTA had adopted the voluntary APTA Standard for Rail Transit Track Inspection and Maintenance as part of the facilities maintenance program referenced in the SSPP , Illinois RTA made a finding that:

• CTA was not using a track geometry vehicle or ultrasonic testing for rail defects, as recommended in the APTA standard.

Based on the training elements identified for track inspectors in the SSPP , Illinois RTA also issued a finding that:

• CTA should develop a course/career outline to guide track inspection training to ensure continuity and repeatability.

However, Illinois RTA did not demand immediate correction of the deficient track conditions noted in its "field observation" because the agency believed this was beyond the scope of its authority. Illinois RTA, based on its review of CTA's Capital Improvement Program and scheduled maintenance program, believed these deficiencies were scheduled to be repaired.

Illinois RTA used a corrective action plan tracking matrix to document its follow-up with CTA:

• CTA had programmed funding for the track geometry machine (which it now uses).
• CTA also had plans in place for a revamped inspector training program including refresher training (which is now in place).

Illinois RTA accepted these responses. NTSB found this approach inadequate. NTSB concluded: "Because the Regional Transportation Authority failed to follow up with the Chicago Transit Authority and prompt action to correct safety deficiencies identified in the triennial report, unsafe track conditions continued to exist that should have been corrected."

Missed Opportunity #4: FTA SSO Program Monitoring

NTSB also cited FTA for failing to make Illinois RTA require corrective actions from CTA to address the observations in its 2004 Three-Year Safety Review. NTSB notes that for a variety of reasons relating to the events of September 11, 2001 and the dramatic increase in the size of the SSO program between 2002 and 2005, FTA failed to stick to its three-year audit cycle for Illinois RTA.

NTSB also pointed out that FTA failed to require and review Illinois RTA's 2004 Three-year Safety Review Final Report, thereby missing an opportunity to require Illinois RTA to demand that CTA develop corrective action plans to address the track deficiencies. NTSB noted that FTA only received the authority to require these reports in its revision to 49 CFR Part 659 published in the Federal Register on April 29, 2005, which went into effect on May 1, 2006. However, NTSB still believed that FTA should have reviewed this report and required Illinois RTA to demand corrective action for the deficient track conditions.

Finally, NTSB cited FTA's failure to ensure that Illinois RTA's SSO program devoted sufficient personnel and technical resources to the oversight of CTA. NTSB determined that these failings were evidence of FTA's inadequate support for the SSO program.

NTSB found that: "The Federal Transit Administration's oversight of the Regional Transportation Authority's Rail Safety Oversight Program was inadequate and failed to prompt actions needed to correct track safety deficiencies on the Chicago Transit Authority's rail transit system."

FTA Response

After laying out the NTSB rationale for its findings, Ms. Boyd then raised some concerns that FTA, Illinois RTA, and CTA have regarding this investigation and its determinations of probable cause and contributing factors. Ms. Boyd noted that the CTA derailment, and the systematic degradation in track conditions that caused it, is a serious accident with important implications for the entire rail transit industry.

However, in its presentation of FTA's 49 CFR Part 659 requirements, Ms. Boyd pointed out that NTSB did not appropriately identify the roles, responsibilities, and authorities of CTA's system safety department, Illinois RTA, the FTA, and the local and State agencies that fund CTA. NTSB implied that the CTA system safety department, Illinois RTA, and FTA had authorities and responsibilities to provide independent quality assurance/quality control (QA/QC) over the performance of track inspection and maintenance activities that are not conferred in 49 CFR Part 659.

Shared Responsibility for Safety Oversight

Based on a limited delegation of Congressional authority, FTA designed the SSO program as one in which FTA, States, and rail transit agencies collaborate to ensure safety and security. Ms. Boyd noted that this program was not created to provide the type of oversight to the rail transit industry that FRA provides to freight railroads and commuter railroads. Instead, this program was designed to reinforce local accountability for the safety and security of rail transit service. In the majority of cases, State oversight agencies and even rail transit safety departments do not enforce compliance with track standards. This activity is traditionally performed by senior management in the maintenance department or by a dedicated QA/QC function.

The 43 heavy and light rail agencies in the SSO program are entities of local government, not for-profit carriers. As such, Congress has determined that they cannot be regulated by Federal interstate commerce provisions. Also, since these agencies do not operate on the general railroad system, except in specific instances where shared use waivers are in effect, they are not subject to FRA jurisdiction, like commuter rail agencies.

Through their legal designations and enabling legislation, Congress has determined that these local agencies remain ultimately accountable for the safety of the service they provide. These agencies are held responsible by their executives, their Boards of Directors, their internal and external auditing functions, their funding partners, the voters in their communities, the statutory requirements specified by States and municipalities in the creation of these public agencies, and tort claims liability provisions.

In the case presented at the hearing, NTSB made assumptions about what could have been done to prevent the derailment based on its familiarity with regulatory programs managed by FRA , particularly 49 CFR Part 213, Track Safety Standards. NTSB also compared the CTA track inspection and system safety programs with "industry standards," developed by the American Public Transportation Association (APTA) in partnership with FTA, and "effective practices" used at Bay Area Rapid Transit (BART), New York City Transit (NYCT), and three commuter railroads overseen by FRA .

NTSB implied that Illinois RTA and FTA should have required implementation of these standards and practices through the SSO program. However, NTSB did not acknowledge that, at the current time, 49 CFR Part 659 does not provide Illinois RTA or FTA with the authority to require implementation of 49 CFR Part 213, APTA Rail Transit Standards, or "effective practices" used at BART or NYCT, or procedures in place at commuter railroads, unless these standards and practices are specifically adopted by the rail transit agency in its SSPP .

Further, NTSB did not clarify that Congress, in the enabling legislation for 49 CFR Part 659, confers no specific enforcement authorities to FTA or the States, such as the authority to issue civil penalties or to suspend revenue service. The SSO program was not established by Congress to ensure correction of all identified defects or deficiencies observed at a rail transit agency, from a missing or burned-out light bulb, to expired fire extinguishers, to specific track defects in specific locations, to requiring the use of specific technology and track testing programs. Rather, the program was designed to provide broad oversight to ensure that the rail transit agency has programs and procedures in place for accomplishing these activities.

"The Power of the Purse"

During the hearing, at several points, NTSB stated that FTA has the "power of the purse" in requiring the implementation of corrective actions and in conferring this authority to State agencies. Yet, FTA is expressly prohibited by Congress from regulating the operations, routes, schedules, and fares of rail transit agencies (49 U.S.C. 5334 (b) (1)). While NTSB's Legal Counsel read this provision during the hearing, he failed to note that this provision is attached to every grant program that FTA manages, including the Section 5307 program, which provides the basis of FTA's authority for the SSO rule.

To date, Congress has limited the authority of SSO agencies to review rail transit agency safety programs and require corrective actions. These limitations stem from the history of "self-regulation" in the rail transit industry and the way in which Congress has structured the SSO program to bridge local, State, and Federal authorities and responsibilities for safety oversight of rail transit agencies. These limitations are based on the reality that the majority of rail transit funding in the United States comes from local and State sources and fare revenues.

FTA is a funding partner, but not the main contributor in keeping the nation's rail transit agencies in service. Congress has made it clear that local and State governments, along with FTA, share responsibility for ensuring the safety of the rail transit systems they fund.

NTSB investigators, upon questioning from the Board, were unable to provide information on CTA's annual operating and capital budgets or the amount of money FTA contributes to these budgets, or the amount of money CTA budgeted for maintenance and actually received between 2004 and 2006. During the lunch break, NTSB investigators obtained this information, but did not present it clearly when the hearing resumed.

CTA's annual operating budget for FY 2008 is projected to be $1.2 billion. As specified by Congress, FTA provides no funds to support this budget. However, local and State agencies are expected to subsidize the elements of this operating budget not covered by fare revenues and other revenues generated by CTA, such as advertising and real estate management. At CTA, fare and other revenues only cover approximately $560 million of the $1.2 billion budget.

For FY 2008, CTA's annual maintenance budget is projected to be approximately $490 million, of which FTA will provide approximately $133 million in Section 5307 funds. FTA also will provide approximately $93 million in Section 5309 Fixed Guideway Remodernization funds and $96 million in Section 5309 New Start funds.

The penalty assigned by Congress for the failure of a State to make "adequate effort" to comply with 49 CFR Part 659 is the withholding of five (5) percent of the Section 5307 funds provided to the urbanized area or State. Therefore, even if FTA had determined that Illinois RTA was not fulfilling its obligations under 49 CFR Part 659 (which it did not), FTA could have withheld $6.5 million from CTA. While this is a sizeable amount of money, it is less than .04 percent of CTA's combined annual operating and capital budgets. FTA's "power of the purse" is limited by Congress, and NTSB should have identified and described this situation accurately.

By failing to correctly depict FTA's authority in the SSO program, NTSB did not recognize that Congress has intentionally limited the authority conferred to FTA in administering the SSO program. Congress views the funding and safety oversight of public transportation as a partnership at the local, State, and Federal levels, not as an exclusive Federal responsibility. Congress expects that State and local funding agencies, working with the rail transit agencies, will do their part to support safety oversight, in partnership with FTA's SSO program.

Resources Devoted to the SSO Program

During the hearing, NTSB determined that the resources Illinois RTA devoted to its SSO program were highly inadequate. Illinois RTA provides .5 full-time equivalents per year plus contractor support.

FTA's Office of Chief Counsel has determined that FTA does not have the authority from Congress to require States to devote specific levels of personnel resources to the SSO program. Nor can FTA require specific qualifications from personnel assigned by the State to manage the SSO program.

Congress also has prohibited FTA from funding the States to cover the costs of addressing 49 CFR Part 659 requirements, with the exception of 5309 funds for States establishing new oversight agencies for New Starts systems. Congress also prohibits the use of Section 5307 funds from covering the costs of salaries for rail transit agency safety personnel. At the current time, as specified by Congress, FTA provides virtually no funding to support the SSO program or the rail transit agency safety departments. Congress structured this arrangement to ensure that State and local partners meet their obligations for overseeing the safety of the rail transit service they fund.

CTA's Budget Crisis and Impacts on Maintenance

NTSB did not cite the extreme under-capitalization of CTA as a probable cause or contributing factor for this accident. FTA is very concerned that NTSB did not use its authority to highlight this issue.

Since the Illinois State legislature failed to reauthorize its State transportation funding bill, Illinois FIRST, in 2004, CTA has been on the verge of bankruptcy. The State of Illinois has provided no funds to support CTA's operating and capital maintenance budgets. As a result, since 2004, CTA's capital maintenance program has declined by almost $400 million and it has received $300 million less than anticipated for operating support. Due to lack of State funding, CTA faced a $110 million deficit in FY 2007 and is projecting an almost $200 million deficit for FY 2008.

For the last four years, CTA has transferred money from its capital budget to sustain operations and cover these deficits. CTA has also cut tens of millions of dollars from its budget. In many ways, the facts of this derailment are actually an itemized listing of the impacts of this protracted budget crisis on CTA's ability to perform adequate maintenance. NTSB noted an insufficient number of maintenance personnel, insufficient time allotted to perform maintenance (no overtime, nighttime, or weekend work), insufficient investment in the training and oversight of maintenance personnel, insufficient scheduling and performance of maintenance activities, and insufficient quality assurance/quality control over critical maintenance functions, such as track inspection. NTSB also identified a "lack of safety culture" and low expectations among employees that critical maintenance activities would actually be performed. Most of these findings are directly attributable to the structural budget deficits forced by the failure of the State of Illinois to meet its funding obligations. This failing has decimated CTA's capital maintenance program.

By not even mentioning this situation, NTSB failed to use its unique position to single out a critical contributing factor to the deteriorated track conditions. Further, the Board failed to make a public statement regarding the obligations of State government to adequately fund the maintenance of aging infrastructure.

SSO Program Verification Requirements

FTA, through its SSO program, provides technical assistance and makes recommendations to rail transit agencies regarding what safety responsibilities should be assumed by their safety functions, their operating and maintenance functions, their QA/QC functions, and their executive leadership. However, ultimately, it is up to each rail transit agency to determine how specific activities, such as track inspection, will be performed, documented in the SSPP , and overseen and reported through the rail transit agency's internal safety audit process. Further, it is left up to each SSO agency to determine how it will assess the rail transit agency's implementation of its SSPP and issue findings requiring corrective action.

For the internal safety audit process, at many rail transit agencies around the nation, executive leadership in the maintenance department performs the field verification and conveys the results to the system safety function. In some cases, joint review committees are established with the system safety function, in other cases, consultants are used to support this activity. The approaches vary considerably in industry, and no two agencies use exactly the same procedures.

CTA's system safety department was not unique in that, prior to the derailment, its system safety officers and engineers were not trained to conduct track inspection, and did not have the authority in the SSPP to review track inspection records or to observe the performance of track inspection. Due to express congressional prohibitions on FTA's authority to regulate the operations of rail transit agencies, FTA's Chief Counsel has determined that FTA does not have the authority to specify how the internal safety audit process is performed, and to require that specific activities to be performed by specific rail transit functions. While FTA recommends that the system safety function assumes a larger verification role in the internal safety audit process, 49 CFR Part 659 does not currently require it.

These limitations also extend to the authority FTA provides in 49 CFR Part 659 to SSO agencies in conducting their Three-Year Safety Reviews. FTA requires the SSO agency, once every three years, to conduct an on-site review at the rail transit agency to determine whether the rail transit agency's SSPP is being implemented and whether it should be updated. SSO agencies issue findings requiring corrective actions when they determine that the SSPP provisions are not being implemented or that the SSPP needs to be updated.

However, while FTA requires an "on-site review" at the rail transit agency, FTA does not specify that the SSO agency must conduct an independent inspection of track, equipment, facilities, or infrastructure as part of its Three-Year Safety Review. Nor does FTA require the SSO agency to demand corrective action plans to correct specific defects or deficiencies identified during onsite inspections.

Ensuring the Integrity of Aging Infrastructure

Finally, FTA is concerned that NTSB did not appear to consider, at any length, whether it was appropriate to have rail transit safety officers responsible for directly overseeing the performance of track inspection and maintenance. FTA believes that how the nation's rail transit agencies ensure the integrity of their track is a critical issue, particularly for rail transit agencies with aging infrastructure.

There are important questions to be addressed in determining how this process should be overseen and who is best equipped to manage it. Rail transit safety officers are not FRA inspectors. They are not trained to perform track inspection; they are not vested parties in labor contracts authorized to evaluate the performance of track workers; and, in most cases, the nation's rail transit safety departments do not have the experience or resources to assume this function. FTA is concerned that by applying the FRA model to the rail transit industry, NTSB overlooked critical distinctions between traditional maintenance QA/QC functions and traditional safety functions.

NTSB Recommendations

Ms. Boyd concluded her presentation by reviewing the recommendations NTSB made as a results of its investigation.

To the Federal Transit Administration:

1.  Modify your program to ensure that State safety oversight agencies take action to prompt rail transit agencies to correct all safety deficiencies that are identified as a result of oversight inspections and safety reviews, regardless of whether those deficiencies are labeled as "findings," "observations," or some other term.

2.  Develop and implement an action plan, including provisions for technical and financial resources as necessary, to enhance the effectiveness of State safety oversight programs to identify safety deficiencies and to ensure that those deficiencies are corrected.

3.  Schedule the Chicago Transit Authority as a priority for receiving the maintenance oversight workshop and the training course to be developed for track inspectors and supervisors that will address the unique demands of track inspection in the rail transit environment.

4.  Inform all rail transit agencies about the circumstances of the July 11, 2006, Chicago Transit Authority subway accident and urge them to examine and improve, as necessary, their ability to communicate with passengers and perform emergency evacuations from their tunnel systems, including the ability to (1) identify the exact location of a train, (2) locate a specific call box, and (3) remove smoke from their tunnel systems.

To the State of Illinois:

5.  Evaluate the Regional Transportation Authority's effectiveness, procedures, and authority, and take action to ensure that all safety deficiencies identified during rail transit safety inspections and reviews of the Chicago Transit Authority are corrected, regardless of whether those deficiencies are labeled as "findings," "observations," or some other term.

To the Regional Transportation Authority:

6.  Determine if track safety deficiencies on the Chicago Transit Authority's Dearborn Subway in the area of the derailment have been adequately repaired.

7.  Strengthen your follow-up action on Chicago Transit Authority system safety reviews to ensure that the Chicago Transit Authority corrects all identified safety deficiencies, regardless of whether those deficiencies are labeled as "findings," "observations," or some other term.

To the Chicago Transit Board:

8.  Direct the Chicago Transit Authority to correct all safety deficiencies identified by the Regional Transportation Authority in its most recent and future safety inspections and reviews, regardless of whether those deficiencies are labeled as "findings," "observations," or some other term.

To the Chicago Transit Authority:

9.  Correct all safety deficiencies identified by the Regional Transportation Authority in its most recent and future safety inspections and reviews, regardless of whether those deficiencies are labeled as "findings," "observations," or some other term.

10.  Examine all of the elements in the American Public Transportation Association's "Standard for Rail Transit Track Inspection and Maintenance" and incorporate all appropriate elements of this standard in your system safety program. Specifically, include the regular use of track geometry vehicle inspections and the inspection of rail for internal defects in your system safety program.

11.  Evaluate all territories to determine the number of inspectors and the amount of time needed to ensure that adequate track inspections are conducted, and implement appropriate changes.

12.  Schedule as a priority the maintenance oversight workshop and the training course that the Federal Transit Administration plans to develop for track inspectors and supervisors that will address the unique demands of track inspection in the rail transit environment.

13.  Perform a comprehensive computational study of the existing ventilation system using various fire and smoke scenarios to identify potential deficiencies, and make improvements to the ventilation system and smoke removal procedures based on the findings of the study. These actions should address reinstalling fan 108 and replacing unidirectional fans (including fan 133) with dual direction fans as needed.

14.  Examine and improve as necessary your ability to communicate with passengers and perform emergency evacuations. Ms. Boyd noted that NTSB would formally transmit these recommendations to FTA and the other agencies in the next few weeks. NTSB will also publish the final accident investigation report, which was approved at the September 11, 2007 Board hearing. In the recommendation letter and final report, NTSB may provide additional clarification regarding what it means by correcting "all safety deficiencies that are identified as a result of oversight inspections and safety reviews, regardless of whether those deficiencies are labeled as "findings," "observations," or some other term."

b. CTA and Illinois RTA Post-Accident Activities

Ms. Boyd then introduced Ms. Violet Gunka from Illinois RTA, who provided both RTA's response to the NTSB investigation and gave an update regarding the activities performed at CTA and by Illinois RTA since the derailment to prevent recurrence.

Ms. Gunka explained that representatives from CTA's system safety department and Illinois RTA watched the NTSB hearing together via webcast at RTA's headquarters on September 11, 2007. Ms. Gunka voiced her agreement with many of the points raised by Ms. Boyd regarding concerns with the NTSB investigation and its depiction of Illinois RTA's authority and FTA's SSO program.

Ms. Gunka also explained that Illinois RTA was not satisfied with the way in which NTSB presented Illinois RTA's 2004 Three-year Safety Review. Though Illinois RTA provided extensive comments on NTSB's Draft Statement of Fact regarding the accident, Illinois RTA does not believe that NTSB adequately addressed their comments. Ms. Gunka also pointed out that, in several interviews with Illinois RTA personnel, it did not seem that NTSB investigators understood FTA's SSO program and how it was different from FRA 's safety program.

Ms. Gunka then reviewed the two NTSB recommendations made to Illinois RTA, and described the activities already underway to address CTA's deteriorating track conditions. NTSB recommended that Illinois RTA:

• Determine if track safety deficiencies on the Chicago Transit Authority's Dearborn Subway in the area of the derailment have been adequately repaired.
• Strengthen your follow-up action on Chicago Transit Authority system safety reviews to ensure that the Chicago Transit Authority corrects all identified safety deficiencies, regardless of whether those deficiencies are labeled as "findings," "observations," or some other term.

Ms. Gunka began her discussion of the activities taken by CTA over the last 14 months to address this derailment by identifying activities performed to locate trains in tunnels and to support emergency evacuations in tunnels under smoke conditions:

• First, a train indicator system that will alert the control center of the location of a train was installed in the State Street, Dan Ryan and the O'Hare subways, and will be installed in the Dearborn and Kimball subways by 2009.
• Second, reflective stationing signs displaying the track stationing number were installed in each of the subway tunnels.
• Third, the emergency response subway maps have been revised and distributed.
• Also, additional lighting will be added to the Dearborn subway to illuminate catwalks during emergencies.

For the area of tunnel ventilation, Ms. Gunka noted that CTA has proposed that the following system improvements should be made; however, because of the budget crisis, funding is currently not available for all these proposed improvements:

• Replace all fans in the tunnels system wide.
• Require that all new fans are reversible.
• Identify fan control in the CTA control center to ensure operators are aware of the direction of airflow.
• Program smoke control matrices into the fan controls that indicate which fans should be on supply and which should be on exhaust during a fire or smoke.

Ms. Gunka then described the activities taken by CTA to address improvements in its track inspection and maintenance program:

• CTA completed a detailed track inspection of the Blue Line Subway, including the derailment area, and all corroded tie plates, lag screws, and rail clips have been replaced.
• A contractor was hired to replace and upgrade all light fixtures in the Dearborn, State, and Kimball Subway tunnels. CTA expects this work to be completed by December 2007.
• CTA contracted with an outside firm to perform track strength and track geometry measurements throughout the entire rail system. Those tests were completed in October 2006 and will be conducted on an annual basis.
• As a result of the track geometry measurements, a number of slow zones and speed restrictions were put in place on the Blue Line and Red Line subway track.
• New grouting initiatives to stem water leaks and to minimize the amount of water in the subway started in November 2006 and will be continued as an ongoing process.
• CTA's Track Standards were revised to incorporate improved track plates that electrically isolate the negative return in the running rails to prevent the corrosion of fasteners.
• A process for the Track Manager and the Roadmaster to review random inspection sheets and to generate a quality assurance memo reviewed by System Safety and the Vice President of Engineering was established in October of 2006.
• A new computerized system with handheld devices for the track inspectors is currently under deployment. The system will be used to maintain and integrated, detailed database for maintenance records and information needed to effectively maintain track.
• On-the-job training for track inspectors has been formalized requiring each inspector to complete specified tasks and to be evaluated on these tasks in the field before they are authorized to officially conduct track inspections.
• A refresher course has been conducted for all track inspectors.
• System Safety staff has undergone track inspector and track standards class and they have accompanied track inspectors on inspections.
• System Safety is conducting time studies of the inspection zones and evaluating whether track inspectors can reasonably cover their assigned territories.

Also, in August, CTA re-organized its track engineering department to separate track inspectors from track maintainers. Also, the department was increased in size by 42 positions and two additional supervisors were also added. Now CTA has:

• 42 positions dedicated to track inspections with 3 foreman overseeing work five days a week, and
• 64 positions dedicated to track maintenance with 6 foremen overseeing work five days a week.

CTA is also working to replace all wooden ties in the subway system, and will continue to use tamping equipment for ballasted portions of track. Tamping helps realign track and stabilizes the ballast supporting the track. A signal system upgrade is also underway. By the end of 2007, CTA will have replaced 4,000 additional rail ties in the Blue Line subway and 4,000 ties in the Red Line subway.

Ms. Gunka noted that Illinois RTA has not yet approved CTA's accident investigation report for July 11, 2006 derailment. In addition to the NTSB findings focusing on track, Illinois RTA has requested that CTA address the following items as part of the investigation report:

• Subway conditions including seepage, limited visibility due to curvature, known maintenance issues, etc.
• Discussion on physical accident findings and issues to back up the conclusion. Analysis and findings related to procedures, the vehicle, and environmental factors.
• Comprehensive assessment of field and control center response versus operating rules and procedural requirements, identifying what was handled appropriately and areas that need improvement.
• Analysis of the security and emergency management response. For example, was turning on the subway fans an appropriate response given what was know about the smoke? Also, what assumptions governed CTA action? Since the Mumbai bombing in India had taken place that morning, could this have been a terrorist attack?
• Discussions regarding the known hazards associated with the Blue Light and the Emergency Stop. What caused the Blue Light? What caused the emergency stop? Are all 31 or so indications for the blue light acceptable hazards?

Ms. Gunka concluded her presentation of Illinois RTA and CTA post-accident activities by reiterating Illinois RTA's concerns regarding the NTSB findings. Ms. Gunka stated that NTSB misrepresented Illinois RTA and the SSO Program. NTSB gave an impression that there was no follow-up on the corrective actions but did not clarify or recognize the fact that neither FTA nor Illinois RTA has the authority to require corrective actions for observed track deficiencies, especially when these observations are made as part of a general review, not the result of an indepth inspection. Further, Ms. Gunka reiterated that none of the observed track conditions identified in the 2004 Three-Year Safety Review were in the area where the derailment occurred.

Ms. Gunka then provided an overview of Illinois RTA's Three-Year Safety Review process. This process begins with an entrance briefing with CTA Executive Staff present, where the SSO program and Illinois RTA's role are discussed, along with the review process and activities. The review itself is a two week process at the end of which an exit briefing is held, which includes the CTA Executive Staff. At the exit briefing, a summary of findings is provided.

Ms. Gunka noted that, as specified in 49 CFR Part 659, the Three-Year Review process carried out by Illinois RTA is a broad review of the implementation of CTA's SSPP and not a QA/QC for track inspection. Ms. Gunka explained that requiring corrective actions for track deficiencies has never been a part of the Illinois RTA SSO program or FTA's 49 CFR Part 659 requirements.

She further noted that Illinois RTA does not have the equipment or the expertise to perform QA/AC for track inspections, nor has there ever been the expectation that Illinois RTA would assume this role. Due to diligence, in its 2004 Three-Year Safety Review, Illinois RTA made observations in the area of track maintenance; however, they were not considered findings. These observations were brought to the attention of CTA Executive Staff and were also included in the Review Report as "observations".

Illinois RTA has a solid relationship with the CTA and other partner agencies. Quarterly meetings are held with participation by CTA, FTA, IDOT and TSA . These meetings facilitate interagency coordination, reporting and information exchange to determine and implement appropriate corrective actions.

Illinois RTA also has a corrective action tracking tool, which includes all corrective actions from Three-year Safety Reviews, Annual Internal Reviews and Accident Investigations. Updates in this tracking matrix are made whenever verification from CTA is received that the corrective action has been completed. Outstanding corrective actions are also discussed during the quarterly meeting.

Ms. Gunka concluded her presentation by stating that Illinois RTA just completed its 2007 Three-year Safety Review of CTA. During this review, Illinois RTA adopted several "lessons learned" from the way in which the NTSB presented its 2004 Three-year Safety Review report. Ms. Gunka noted that Illinois RTA has made changes in the formatting of its report, and in the classification of its findings. Illinois RTA also decided not to include any observations, recommendations, or other information that was not germane to a specific finding.

c. Implications for FTA's SSO Program

Mr. Taborn thanked Ms. Gunka for her presentation, and then offered his perspective on the NTSB investigation, as the Director of FTA's Office of Safety and Security.

Mr. Taborn noted that the CTA accident and the gradually deteriorating track conditions that caused it raise many important issues. One of them is the appropriate level of Federal regulation in the public transportation industry. Another is how municipalities and States, facing budget deficits, can provide sufficient resources to support the maintenance of aging infrastructure. Finally, Mr. Taborn observed, that when confronted with the facts of this accident, we must be concerned that perhaps such an event could happen again at another public transportation agency.

Mr. Taborn noted that, as both Ms. Boyd and Ms. Gunka observed, FTA does have concerns with the NTSB investigation and the investigative process used to assign responsibility for this derailment. Mr. Taborn explained that FTA does not believe that NTSB appropriately identified the roles, responsibilities, and authorities of the involved parties as specified in 49 CFR Part 659. Mr. Taborn explained that FTA is still assessing NTSB's determinations regarding the appropriate role of the rail transit safety function, the SSO agency, and FTA in overseeing the performance of track inspection and maintenance.

Mr. Taborn further noted that FTA can argue with NTSB about these roles and responsibilities, and about who is accountable for performing which functions. FTA can also dispute NTSB claims that Part 659 provides adequate delegations of authority to SSO agencies to require corrective action plans for every identified safety deficiency, from a missing or burned-out light bulb to specific track conditions in specific locations, to requirements in training and qualification programs, to the use of specific technology and testing programs.

However, Mr. Taborn pointed out that FTA cannot deny that a hazard continued to exist at CTA that was neither reported to nor managed through the SSO program at any level. Mr. Taborn explained that, since the derailment, FTA has worked closely with CTA and Illinois RTA to support the turn-around in CTA's track inspection and maintenance program. FTA has also taken a hard look at its administration of the SSO program. Mr. Taborn then noted that, that while it was not a focus of the NTSB investigation, FTA's biggest concern with the derailment is that at all levels of our SSO program, we did not intervene effectively through the hazard management program to identify and manage an ongoing hazardous condition.

Mr. Taborn explained that on September 6, 2007, FTA released a letter clarifying 49 CFR Part 659 hazard management program requirements and urging improvements in their implementation. Mr. Taborn noted that this letter was discussed extensively yesterday, and that he hoped the participants had a better understanding of these requirements. Mr. Taborn explained that while it will take many months, perhaps years, to address the NTSB recommendations from the CTA derailment fully in the SSO program, he did want to take a moment to discuss new initiatives that FTA has in place to support immediate improvements. At roundtables, workshops, and meetings like this one, FTA has given presentations with representatives from both Illinois RTA and CTA on this accident and the actions now being taken by CTA to improve its maintenance program. FTA has tried to explain how this situation occurred, and to highlight indicators and precursors that agencies at all levels can use to catch and manage these conditions before an accident occurs.

In the SSO audit program, FTA has placed special emphasis on the requirements of the hazard management program, ensuring that both rail transit safety functions and the SSO agency are made aware of potential maintenance concerns. FTA has also developed a new Track Worker Protection and Maintenance Oversight Initiative, which was introduced in Administrator Simpson's Dear Colleague Letter of May 8, 2007.

Beginning in FY 2008, FTA plans to conduct two-day workshops at four heavy rail transit agencies. These workshops will include maintenance, operations and safety personnel, executive leadership, and State safety oversight personnel, and will explore maintenance safety oversight challenges and attempt to identify possible options for improvement. FTA plans to use these workshops to galvanize the attention of industry on maintenance and safety issues. These workshops will also support the development of guidelines on improved maintenance practices in the rail transit environment.

FTA also plans to develop a track inspector refresher training course, which will be piloted at four other heavy rail agencies in FY 2008, then offered to the entire industry in FY 2009. FTA will also develop a training video/DVD specifically on track worker protection. FTA will also prepare pocket guides on track inspection and track worker protection for use in the field.

FTA is working to update its highly successful Transit Watch program to include safety issues for employees and passengers. Through this new initiative, transit agencies will have templates, brochures, posters and other materials available to support adherence to safety rules and to prevent at-risk behavior.

FTA also will be conducting outreach directly with rail transit agency chief executive officers (CEOs) regarding track worker protection and maintenance oversight issues.

In the last year, FTA has developed a training curriculum for State oversight personnel, and is providing financial support to enhance their professional development and certification through the World Safety Organization (WSO).

FTA will continue to support research regarding track inspection and track worker protection, and will continue to coordinate with APTA regarding the development of consensus-based, voluntary standards through the APTA Rail Transit Standards Program. Finally, FTA will also continue to sponsor research through the Transportation Research Board (TRB), Transit Cooperative Research Program (TCRP), and the University Transportation Centers (UTCs).

Mr. Taborn then called Mr. Mike Flanigon to the podium to provide a few words about the CTA derailment and the NTSB findings and recommendations. Before joining FTA as the Director of FTA's Office of Technology, Mr. Flanigon was a rail transit investigator for NTSB, and in the first few months after the CTA derailment, served as the NTSB Investigator-in-Charge.

Mr. Flanigon pointed out that there are really two parts to the NTSB's investigation and findings. The first part is the way in which NTSB interpreted FTA's legal authorities and the role of the SSO agencies and rail transit agency system safety departments as specified in 49 CFR Part 659. Mr. Flanigon explained that, often, when NTSB wants to see a change in policy, they will make a recommendation to the appropriate Federal agency, rather than directly to Congress. He pointed out that this may have been the case with the CTA investigation findings and recommendations.

Mr. Flanigon noted that while members of the SSO community could ask whether it was appropriate for NTSB to make the findings it did, the SSO community needs to appreciate the extreme deterioration of CTA's track. This was not a case of an isolated segment of track in poor condition. The entire track in the Blue Line subway was in very bad condition. Mr. Flanigon noted than in his office at FTA he has a portion of the fixation system from CTA's track that came loose after he pressed on the rail with his hand.

Mr. Flanigon stated that based on his experience, his biggest concern was that CTA had track standards in place, which required that speed restrictions be imposed on wide gage track or, depending on the extent of the gage problem, that the track be removed from service. For whatever reasons, these track standards were not enforced by CTA inspectors, roadmasters, foremen, and senior management. No one at any level intervened effectively to address these conditions or to impose speed restrictions. Therefore, wide gage track was allowed to remain in service, and trains were allowed to operate over this track at inappropriate speeds. As a result, a derailment occurred that should never have happened.

Mr. Flanigon noted that CTA has fired the individuals involved for negligence, the General Manager has stepped down, and CTA has since re-vamped both its track inspection and maintenance program. However, Mr. Flanigon observed that none of this post-accident activity can erase what was a truly deficient condition regarding the enforcement of CTA's track standards. This is a wake-up call to the rest of the industry, particularly for those agencies that, like CTA, have aging infrastructure.

Mr. Flanigon pointed out that it is incumbent on each rail transit agency, its safety function, and its oversight bodies to ensure the integrity of the internal processes put in place to safeguard the integrity of critical systems, such as track. Mr. Flanigon also agreed with Mr. Taborn that there are complex issues involved in determining how oversight functions can effectively identify and address these types of issues through the hazard management program, the conduct of on-site reviews and inspections, and other means.

Questions and Answers

Based on the presentations, there were a number of questions from participants at the 11th Annual SSO Program Meeting:

• Under-capitalization: There was considerable discussion regarding the impacts of under-capitalization on rail transit systems with aging infrastructure. Participants expressed their frustration that the safety function would be held accountable for the impacts of wide-spread failings of State and local political processes to generate sufficient funds to sustain infrastructure, and the way these impacts filter through capital improvement programs and executive leadership. FTA representatives explained that they expected, as a result of its investigation, that NTSB would find that State and local governments had failed to adequately fund needed maintenance repairs at CTA. FTA did not anticipate that NTSB would classify this accident as a "failure of safety oversight at all levels." FTA reiterated its disappointment that NTSB did not address the deteriorating financial conditions at CTA, which clearly played a major role in the degradation of the track. FTA noted that by saying nothing about these conditions, NTSB did use its unique position to address an endemic problem that is a challenge for so many agencies with aging infrastructure. However, FTA also recognized that, through the SSO program, we must all do whatever we can to ensure safe service, perhaps most especially, when our agencies are facing extreme budgetary restrictions. In light of the NTSB hearing, FTA urged SSO agencies and rail transit agencies to review their current SSPP verification processes and to determine if they were comfortable with them.
• Making Findings during Audits and Reviews: Participants had concerns regarding the NTSB's recommendation that FTA modify the SSO program "to ensure that State safety oversight agencies take action to prompt rail transit agencies to correct all safety deficiencies that are identified as a result of oversight inspections and safety reviews, regardless of whether those deficiencies are labeled as "findings," "observations," or some other term." Questions were asked regarding both what NTSB meant by "safety deficiency" and why NTSB did not acknowledge that there is a significant difference between a "finding" and an "observation" based on the authority of the SSO agency to require corrective actions (i.e., in the case of Illinois RTA, "findings" required corrective action based on Part 659 authority and "observations" were made to document review activities, to provide courtesy information to the rail transit agency, or to identify recommendations or effective practices for consideration). FTA responded that it hopes to receive additional detail in the NTSB report and recommendations letter.
• Auditing as a Professional Discipline: Several representatives from rail transit agencies expressed their opinions that auditing, like many other transit functions, is a professional discipline. Auditors, whether they are rail transit agency staff, industry personnel, contractors, SSO personnel, or FTA personnel, should be trained and qualified. A critical part of conducting an audit, as a trained and qualified auditor, is recognizing that issues of authority are not decided when the report is being drafted, but much earlier, when the audit scope, checklists, and verification processes are being established. These rail transit agencies representatives noted their opinions that:
  • Auditors should clearly define the scope of their audits. Before they begin, they should know their authority to issue findings and to require corrective actions.
  • Based on this understanding of scope, auditors establish their checklists. Each item in the checklist must be backed by a specific requirement that should be implemented, as identified in Part 659, the SSO Program Standard, the transit agency's SSPP , and supporting rules and procedures.
  • Items that are not required should not be included in the scope of the audit or in the audit checklist.
  • erification activities to be performed by auditors or others should be specified for each checklist item or category of checklist items.
  • Auditors should have clear acceptance criteria regarding what is necessary to meet each requirement identified in a checklist item or category of checklist items.
  • Findings should be issued only in those areas where verified evidence demonstrates the failure to meet the acceptance criteria for a referenced checklist item or category of checklist items.
  • It is best if the finding of non-compliance with a particular checklist item or category of items is issued to the rail transit agency department responsible for those items. Then, this department is responsible for developing a corrective action plan, which will be approved, implemented and tracked by that department, with on-going reporting to the safety function and verified evidence that the corrective action plan has been implemented.
  • Depending on its authority, the safety function may be involved in the approval process for the corrective action plan developed by the rail transit department.
  • Auditors should never inject their own opinions or recommendations.
• The Role of Recommendations and Effective Practices in Supporting Continuous Improvement: Some representatives from rail transit agencies and SSO agencies agreed that, in light of the NTSB recommendations, perhaps it was time to take a hard look at how findings were made and documented in rail transit agency internal safety audit reports and SSO Three-Year Safety Reviews. However, some representatives felt that there were important benefits to be gained from making recommendations and identifying effective practices for consideration, even if these items did not relate to whether minimum acceptance criteria for a specific checklist item had been addressed. These representatives noted that anything in writing could, potentially, be used against the rail transit agency department or SSO agency at some future date. However, there was some discussion regarding whether including these items could support continual improvement and awareness at all levels of the rail transit agency, and if this activity was not part of what the rail transit safety function and the SSO agency was supposed to be doing in making determinations regarding whether the SSPP should be updated. There was also discussion regarding whether safety auditing/review processes should be "defensively" oriented - focusing on compliance only, or "offensively" oriented - focusing on improvements and future activities.
• Role of Automated Technology: There was also some discussion regarding whether FTA would ever consider developing an automated tool to support the conduct of internal safety audits and Three-Year Reviews, the making of findings, and the tracking of corrective action plans. FTA responded that it was highly unlikely that FTA would ever assume this role. However, FTA encouraged the incorporation of automated tools into safety auditing programs where appropriate.

6. UNIVERSITY TRANSPORTATION CENTER RESEARCH PROGRAMS

Mr. McElveen thanked everyone for the great discussion regarding the challenges we are currently facing in conducting audits and reviews. After a short break, Mr. McElveen then introduced Mr. Michael Flanigon, Director, FTA Office of Technology, and Ms. Lisa Colbert, Transportation Program Manager, FTA Office of Research, Demonstration, and Innovation. Mr. McElveen explained that over the past year, he has been working closely with Mr. Flanigon and Ms. Colbert to identify additional opportunities for incorporating safety issues into FTA's research programs.

Mr. Flanigon kicked off the session by summarizing the activities and responsibilities of FTA's Office of Technology. Mr. Flanigon noted that his office works with University Transportation Centers (UTCs) and other organizations and agencies to evaluate rail technologies and programs that can be used by the rail industry to improve system safety and security.

Mr. Flanigon next stated that the FTA appropriated $80.5 million during FY 2007 to various research programs and organizations including the National Research Program, the Transit Cooperative Research Program, the National Transit Institute, UTCs, Capital Investment Grants, and Non-FTA funded programs involving intelligent transportation systems (ITS) and Maglev technologies. In addition to these existing programs, Mr. Flanigon stated that FTA has recently awarded and started programs for Preventing Rail System Suicides and Machine Vision Intrusion Detection. FTA is currently evaluating programs for Train Operator Post-Traumatic Stress Syndrome Studies and Third Rail Insulator Cleaning Technology Demonstrations.

Mr. Flanigon also explained that FTA is involved with a Shared Track Research program that will look at specific separated shared use operations and identify specific technologies that could work on these systems. This program builds on the joint efforts of the FRA Office of Research and Development, and the FTA Office of Research, Demonstration, and Innovation. The goal of this program is to explore the feasibility of shared use operations of passenger and freight trains using ITS to ensure system safety is maintained or improved through the use of these technologies. FTA also supports the current Crash Energy Management Program, which focuses on improving railcar designs to better withstand the impacts of collisions.

Additionally, FTA is developing a Safety Auditor Training Program that will help address NTSB recommendations stemming from the CTA derailment and other previous accidents where rail transit agency internal oversight could have been improved. The objective of this program is to develop lesson plans, graphics, workbooks and other materials to help safety auditors be the best they can be, providing them with a greater level of qualification and education to identify $100,000 in FTA funding in FY 2007.

FTA is also excited to be expanding its research into different crash energy management technologies including the use of end of track devices, car interior features, testing and simulators, and diesel multiple unit (DMU) fuel tank crash resistance. FTA is also exploring different security related technologies for use in the rail transit environment including web based station simulators, train operator emergency training simulators, harnessing machine vision technology, and WiFi operations control center subway train communication links to passengers. Mr. Flanigon concluded his presentation be soliciting feedback from the audience and asking that they please provide any ideas they may have for additional research topics to his office.

Ms. Colbert next discussed FTA's relationship with the UTCs, explaining how FTA works in partnership with the UTCs to develop better transit education, research and technology resources for the industry. Through FTA's Office of Research, Demonstration, and Innovation, Ms. Colbert is responsible for managing the UTC program for FTA by increasing FTA's involvement with the UTCs, and fostering collaboration between transit agencies, private organizations, and the UTCs.

Ms. Colbert provided a brief history of the UTC program, stating that in 1987, the Surface Transportation and Uniform Relocation Assistance Act established the program and created a UTC in each of the ten Federal regions. In 1991, the Intermodal Surface Transportation Efficiency Act (ISTEA) reauthorized the UTC Program and increased the total number of UTCs from 10 to 20. In 1997, the Transportation Equity Act for the 21st Century increased the UTC program to 33 Centers nationwide, and finally, enacted in 2005, the Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users (SAFETEA-LU) created 60 UTCs.

Ms. Colbert explained that while the UTCs are funded by the FTA and FHWA, they are administrated by the Research and Innovative Technology Administration (RITA), and that legislation has been used to categorize the UTCs into five groups based on funding amounts. There are currently ten national UTCs with funding of $3.5 million per year, 10 regional UTCs with $2 million in funding per year, 10 Tier I UTCs that receive $1 million in funding per year, 22 Tier 2 UTCs that receive $500,000 in funding per year, and eight Tier 3 UTCs that receive between $400,000 and $2 million in funding each year.

In 2006, the UTCs listed as Regional and Tier I were subjected to a competition. As a result, six new candidates entered the program in 2007. All of the DOT modal administrations participated in the evaluation process.

The UTCs have requirements they must abide by. These include:

• Funding - 52 of the UTC's require a 100% non-Federal match, except for the 8 -Tier 3, UTC's which are funded by FTA.
• Each UTC must develop a multi-year Strategic Plan setting out the activities to be undertaken during the life of the grant to achieve the six goals of the program.
• RESEARCH SELECTION: - Establish an objective process for selecting and reviewing research that balances multiple objectives of the program.
• RESEARCH PERFORMANCE - To conduct basic and applied research, the products of which are judged by peers or other experts in the field to advance the body of knowledge in transportation.
• EDUCATION - To promote a multidisciplinary program of course work and experiential learning that reinforces the transportation theme.
• HUMAN RESOURCES - To increase the number of students, faculty and staff who are attracted to and substantively involved in the undergraduate, graduate and professional programs of the UTC.
• DIVERSITY - To engage students, faculty and staff who reflect the growing diversity of the US workforce and are substantively involved in the undergraduate, graduate and professional programs of the UTC.
• TECHNOLOGY TRANSFER - The research products produced should be available for potential uses in a form that can be directly implemented, utilized or otherwise applied.

In addition, each UTC must develop a Theme that encompasses more than one mode of surface transportation and clearly links to the national strategy for surface transportation research. Each UTC is expected to devise and implement a process for selecting research projects that includes peers and other experts in the field, including at least one individual from the U.S. DOT . Additionally, each UTC is required by law to be supportive of the National Strategy for Surface Transportation Research as defined by (1) the report of the National Highway Research and Technology Partnership entitled Highway Research and Technology: The Need for Greater Investments dated April 2002, and (2) the programs of the National Research and Technology Program of the FTA. Each UTC is also strongly encouraged to support the national research, development, and technology high-priorities of DOT and its Operating Administrations, as identified by the DOT Strategic Plan, the U.S. DOT Research, Development, and Technology Plan, and other items that RITA may post on the UTC program's web site. There are two DOT -wide activities: (1) Advanced Research and (2) Congestion Chokepoints.

The mission of the UTC is to advance U.S. technology and expertise in the many disciplines comprising transportation through education, research, and technology transfer at universitybased centers. Through partnerships with state and local transportation agencies, governments and the private sector, the universities serve as important sources in developing transportation leaders and innovations to meet the nation's need for safe, efficient, and environmentally sound movement of people and goods.

Each UTC publishes a semi-annual Informational Center Newsletter, and an annual report that details that Center's research, education, and technology transfer results, and publishes research reports. These results are available on the UTC's website. In addition, published reports are cataloged in the Transportation Research Information Service (TRIS) database and the National Transportation Library. When UTCs first select research projects to be conducted, each UTC submits to the Transportation Research Board's Research in Progress (RiP) database a project description of each project. The UTCs also contribute in unique ways to these objectives (research, education, & technology transfer).

Ms. Colbert further explained that various UTCs conduct basic and applied transportation research in numerous, multimodal fields; aid workforce development by creating programs for the professionals and providing undergraduate and graduate students an education program that includes multidisciplinary course work and participation in research; and make these research and education results available through an ongoing program of technology transfer that can be implemented, utilized, or applied. She then provided a listing of each of the UTCs grouped by as follows:

Hazard probability can be measured as follows:

FTA currently provides $7 million in annual funding to support 8 of the UTCs. These include:

• Jackson State University - Theme: Institute for Multimodal Transportation (IMTrans)
• North Dakota State University - Theme: Rural Transportation (center name: Small Urban and Rural Transit Center)
• University of AL, Birmingham - Theme: Traffic Safety and Injury Control (center name: U. of AL at Birmingham UTC)
• University of AL, Tuscaloosa - Theme: Management and Safety of Transportation Systems (Center name: UTC for AL)
• University of Denver/Mississippi State University - Theme: Assessment, Planning, and Design of the Nation's Intermodal Transportation (center name: National Center for Intermodal Transportation)
• University of Tennessee - Theme: Heavy Vehicle Safety, Efficiency, and Security (center name: National Transportation Research Center, Inc. (NTRCI)
• Morgan State University - Theme: Transportation: A Key to Human and Economic Development (Center name: National Center for Transportation Management, Research, and Development)
• Texas A&M University - Theme: Improving Quality of Life by Enhanced Mobility (Center Name: UTC for Mobility)

Ms. Colbert next provided several examples of UTC research projects. These included San Jose State University's "Increasing Transit Ridership: Lessons Learned from the Most Successful Transit Systems in the 1990's," which looked at external and internal factors that impact ridership and what measures transit agencies can implement to increase ridership. The report became the basis of a ridership course at the National Transit Institute.

The second exampled was a collaborative effort between North Dakota State University,Colorado State University, the University of Utah, and the University of Wyoming. This study was conducted to identify ITS technologies that transit systems are using, and particularly to aid in the progress of the Welfare to Work Initiative.

Ms. Cobert's final example was a study conducted by Texas Southern University to measure the potential impacts of transportation facilities on land values. The findings indicated that transit bus facilities are not overriding variables causing changes in land values. Other UTC research projects include the 1999 Transit Customer Satisfaction Index, which was conducted by the University of South Florida to provide a systematic evaluation of participating transit authority's customer satisfaction, insight into the factors that drive customer satisfaction, and recommendations for how to increase customer satisfaction. Also mentioned was another study conducted by the University of South Florida pertaining to land developer participation in providing for bus facilities and operations.

In 2006, FTA conducted 3 dialogue sessions with UTCs and the transit industry:

(1)  APTA Bus and Paratransit Conference (CA)

(2)   Community Transportation Association of America (FL)

(3)   APTA Rail Conference (NY)

The purpose of these sessions was to introduce FTA and to establish a relationship with the UTCs; to provide a private sector network group for the UTCs; to inform UTCs about the FTA Strategic Research Plan and goals; to obtain an understanding of how the UTC program operates; and to identify what the UTCs expectations were of FTA.

In 2007, FTA continued to formulate a relationship and conduct outreach activities with the UTC community, and now participates on 10 UTC Advisory Boards and has visited at least 4 separate UTC facilities. To date FTA has conducted three roundtable meetings and two workshops at UTCs. The purpose of the meetings was to discuss real transit problems that were suggested by the transit industry; to share and exchange ideas about the topics; to determine how important the topic were on a national or regional level; and to prioritize the topics.

Ms. Colbert concluded her presentation by briefly introducing each of the UTC representatives in attendance at the 11th Annual SSO Meeting. Representatives from the UTCs that delivered presentations included Dr. Reinhardt Brown, Interim Executive Director, South Carolina State University; James E. Clyburn University Transportation Center, Center of Excellence in Transportation; Dr. Jill Hough, Director, North Dakota University, Small Urban & Rural Transit Center; Dr. Mahmud Farooque, Ph.D., Center/Managing Director, NEXTRANS, Purdue, Regional University Transportation Center; and Dr. Max Donath, Director, University of Minnesota, Intelligent Transportation Systems Institute.

The representatives from the UTCs delivered various presentations pertaining to their programs during the remainder of the UTC Research Programs Session. At the conclusion of this session, Mr. McElveen opened the floor to questions and asked that the audience think about and provide the UTCs with potential research topics. Mr. McElveen also noted that the rail transit industry is currently seeing a significant trend in losing experienced personnel and managers due to retirements. He then suggested that UTCs consider conducting a research project in how the rail transit industry might better identify and hire qualified rail transit safety professionals.

Some participants suggested potential areas of research for the UTCs. Suggested topics included:

• Technology that warns track workers of oncoming vehicles in the Right-of Way;
• Guidelines and recommendations for how to lower the cost of equipment, such as track geometry vehicles, water and vacuum trains, and tamping equipment (through sharing programs, leasing programs, joint investment programs, etc.); and
• How to get college students to enter the field of transit safety.

7. OPERATION LIFESAVER

Ms. Isabel Kaldenbach, National Director, Light Rail Safety Education, Operation Lifesaver, Inc. began her presentation with an overview of Operation Lifesaver. The organization was founded in 1972 when the annual average of collisions at highway-rail grade crossings exceeded 12,000. At that time, a six-week public awareness campaign called "Operations Lifesaver" was sponsored by the office of Governor Andrus, Idaho Peace Officers, and the Union Pacific railroad. The campaign grew, and during its first year, Idaho's crossing-related fatalities dropped by 43 percent.

From its origins in Idaho, Operation Lifesaver has grown exponentially and is now a National organization with six international partners, and over 3,000 trained presenters. The continuing goal of the organization is to educate drivers and pedestrians with regards to the hazards of rail grade crossings and trespassing on railroad property. Through education, Operation Lifesaver has worked to eliminate death and injuries at rail grade crossings and on rail rights-of-way. Since 1981, the number of annual fatalities related to rail grade crossings has dropped by almost 50 percent (from 728 to 362) and the total number of collisions at crossings has dropped by over 65 percent, from 9,295 to 2,897.

Ms. Kaldenbach next explained how Operation Lifesaver developed its safety campaign for light rail transit. This program, which meets a need identified by many light rail agencies, as well as federal policymakers, was developed jointly by the Federal Transit Administration and Operation Lifesaver, with significant assistance by the American Public Transportation Association (APTA). Ms. Kaldenbach noted that the complete program is available on Operation Lifesaver's website at: http://www.oli-lightrail.org

Ms. Kaldenbach explained that developing this program for the light rail environment was challenging. While light rail is one of the fastest growing modes of transit in the country, it is not widely understood by the public. Unlike traditional rail (Amtrak, commuter lines, freight railroads) or buses, light rail programs vary enormously from city to city, in operation and infrastructure. Some have dedicated lanes, while others share street corridors; some equipment looks like traditional train equipment, some like early-20th century streetcars. Light rail systems run at different speeds, and face different operating hazards.

Ms. Kaldenbach also noted that some light rail systems have vehicles that resemble buses on steel wheels; some light rail trains operate in the center median, some at curbside, and others are completely off-street. Because light rail cars are quieter, bi-directional, more frequent, and often operate right on city streets, long-established safety programs for traditional rail were not applicable to light rail. Finally, since light rail agencies are heavily funded by local agencies, messages developed for the program would have to cater to a very local clientele.

Ms. Kaldenbach explained that it took a great deal of research and discussion to create a safety education program whose characters, situations, and messages were widely applicable to this mode of transit. The messages had to resonate across widely divergent light rail systems, and the character had to be sensitive to the traveling public in various cities and its endless variety of ethnicities, ages, income levels, disabilities, and of course, both genders.

To develop its messages and character, in January of 2003, Operation Lifesaver compiled a list of agencies that either considered themselves light rail, were widely (if erroneously) viewed as light rail by the general public, or were not light rail at all but had extensive rail safety education experience (for example, Long Island Railroad). Also, Operation Lifesaver compiled a list of areas that did not have light rail yet, but had planning and development well underway -- since educating people who have never seen light rail in their neighborhood is a particular challenge.

Early in 2003, Operation Lifesaver invited 44 transit agencies across the country to participate in developing this program, and made presentations at several public transit conferences throughout the year to introduce as many agencies as possible to the developing effort. Ultimately, 23 agencies and a half dozen experts with previous experience in the transit world came together to help design the program, agree on a character, and most importantly identify core messages that could help educate customers, future customers, motorists, pedestrians and neighbors about light rail safety.

Through regular conference calls, a listserve, and email contact, seven messages were identified (with three to four sub-messages for each) and a character and story line were developed. After rejecting some proposals, the group unanimously agreed on Earl P. Nutt, a squirrel who travels the country, seeing the sites. Various story lines were developed that could place Earl in amusing but educational situations as he travels light rail lines across the country. Ms. Kaldenbach noted that the Earl cartoon is "cute" enough to appeal to younger audiences, but his character is edgy and savvy enough to appeal to older children more drawn to Bugs Bunny, SpongeBob, and the Simpsons.

Once the group agreed on Earl and his messages, Operation Lifesaver and the educational and graphic design firm Flying Rhino developed collateral materials, including:

• A 4-minute cartoon and 10-second public service announcement
• Artwork and signage (posters, advertising cards for the inside of transit vehicles, theater slides, clip art that can be used as needed by agencies)
• An activity book targeted at 4th to 8th graders
• A speaker's handbook

In the fall of 2003, the first packages of materials were distributed to agencies to be tested in their operations. The agencies were:

• New Jersey Transit, serving the entire state
• Portland, Oregon
• San Jose, California
• Salt Lake City, Utah
• San Francisco, California
• Seattle, Washington

Since 2003, the campaign has expanded beyond school children. Materials have now been developed for teenagers and adults. Ms. Kaldenbach noted that that these materials are very different from what Operation Lifesaver had done in the past. However, through a comprehensive pilot program, the organization actively sought feedback from the children and others who participated in the initial training programs. Through this feedback, Operation Lifesaver learned important lessons regarding what worked and what did not work in the rail transit environment. Operation Lifesaver made adjustments to the organization's programs based on these comments.

Today, Operation Lifesaver offers and produces a wide variety of education manuals, fact sheets, posters, brochures, and checklists for presenters. Many are based on the character of Earl P. Nutt that can be customized to fit the transit agency needs including using the transit agency's own logo in the brochures. Many of the materials are also bilingual. The material -- distributed free of charge to any transit agency that requests it -- is designed to be used as individual transit agencies like, to meet their needs. Agencies can pick and choose among the offerings, drop their logos into the artwork, and/or adapt the artwork and messages for use in their efforts. All materials are being made available in a variety of formats, which should make it easy for an in-house agency or contracted graphic designers to adapt them.

If agencies decide they would like to develop their own cadre of local presenters, Operation Lifesaver also will train its local speakers to be presenters using these materials. At the conclusion of her presentation, Ms. Kaldenbach took questions. Ms. Kaldenbach was asked if Operation Lifesaver has any training programs that might be useful specifically for the SSO community. She responded that SSO representatives can attend training, or if interested, can become certified Operation Lifesaver trainers, but no program has been developed specifically for SSO Program Managers.

An audience member asked if the Operation Lifesaver program addresses Americans with Disabilities Act (ADA) issues. Ms. Kaldenbach stated that these issues are not yet extensively addressed by the program; however, it is an area of interest that the program may pursue in the future.

In a related question, Ms. Kaldenbach was asked how senior citizens were included in the program. She stated that they receive information through community outreach programs similar to the standard programs issued by Operation Lifesaver. Next, Ms. Kaldenbach was asked if the program includes examples of accidents or near misses.

She replied that this is done primarily through the state coordinators, who should be contacted if the participants were interested in getting more information about the programs in their respective states.

Finally, one participant asked if the program could be extended to include Security. Ms. Kaldenbach stated that this was a possibility, but that no action is currently being taken to incorporate security issues.

8. PARTNERING FOR RAIL TRANSIT SECURITY OVERSIGHT

Mr. Rick Gerhart, Security Team Leader for FTA's Office of Safety and Security, facilitated the panel on partnering for Rail Transit Security Oversight. Mr. Gerhart began his session by relating a humorous story on the importance of teamwork from the days when Casey Stengel managed the "lovable loser" New York Mets.

Mr. Gerhart then turned to a more serious matter. He explained that FTA's Office of Safety and Security is in the process of developing a Five-Year Strategic Plan ( FY 2008 through FY 2012). In Fiscal Year 2007, Mr. Gerhart stated that FTA's Office of Safety and Security initiated this planning process by collecting data through interviews with FTA staff (inside and outside the Office of Safety and Security), Federal partners (e.g., staff from the Federal Railroad Administration, Federal Motor Carrier Administration, Office of the Secretary, Department of Homeland Security, including the Transportation Security Administration [TSA]), and transit industry stakeholders (e.g., the American Public Transportation Association and Community Transportation Association of America). The Office also reviewed FTA guidance documents and other materials as part of data collection.

Based on analysis performed from this information collection, FTA's Office of Safety and Security then mapped out an approach for the next five years to assure that its safety, security, and emergency management programs are balanced based on industry needs, driven by clear goals, and assessed for utility and effectiveness on a regular basis.

Mr. Gerhart noted that the purposes of the Five-Year Strategic Plan are to:

• Assure a long-term view and regular assessment of FTA's safety, security, and emergency management programs and activities;
• Prioritize FTA products and activities consistent with available resources;
• Identify opportunities for integration and synergy with safety, security, and emergency management activities at FTA, with Federal partners, and within the transit industry; and
• Coordinate evolving safety, security, and emergency management programs and activities with Federal partners and the transit industry.

Mr. Gerhart explained that, through this strategic planning process, FTA is developing a longterm work program to help FTA meet three goals:

1.  Expand Office of Safety and Security outreach and customer service with FTA Regional Offices, public transportation agencies, other Federal partners, and State oversight agencies.

2.  Integrate and improve safety, security, and emergency management programs, building on the benefits of an all-hazard approach for training, technical assistance, and partnerships with industry.

3.  Enhance training management program to build core competencies in safety, security, and emergency preparedness, emphasizing, wherever possible, all-hazard approaches.

Mr. Gerhart concluded his discussion of the Five-Year Strategic Plan by telling the participants that a brochure explaining this process is available on FTA's safety and security website, and that the final Five-Year Strategic Plan will also be posted there when it is completed later this year.

TSA BASE Program

Mr. Gerhart then introduced Mr. Peter Roe, Branch Chief, TSA Surface Transportation Security Inspection Program (STSIP). Mr. Roe also began his presentation by recounting another New York Mets story from the 1960s.

Then, Mr. Roe provided an update regarding TSA 's findings from its Baseline Assessment for Security Enhancement (BASE) program. Mr. Roe noted that TSA 's Fiscal Year 2007 goal for the transit industry included completing BASE reviews of the 50 largest transit agencies based on ridership. To date 44 of these reviews have been completed and five others are currently in progress. TSA 's Fiscal Year 2008 goal includes completing BASE reviews on transit agencies ranked 51 through 100, again based on ridership.

Mr. Roe provided an overview of the process used to conduct the BASE reviews. Mr. Roe noted that BASE is a tool to provide uniform guidance to Transportation Security Surface Inspectors and security auditors for review of transit agency security programs. TSA 's Mass Transit Division and STSIP developed the tool in support of the program goals to:

• Identify Security Gaps
• Identify Effective or "Best" Security Practices

The BASE program assesses security posture at each reviewed agency, gathering baseline security program data, and facilitating security enhancement in mass transit systems nationally.

Mr. Roe noted that the reviews conducted in the BASE program are guided by a detailed checklist built on TSA and FTA Security and Emergency Management Action Items (including 17 core areas that are considered the foundation of an effective security program), TSA 's Transit Security Fundamentals, the security requirements of 49 CFR Part 659, and TSA 's Security Directives for rail-based passengers systems. This checklist is used to evaluate program components using standard audit practices through document reviews, interviews with personnel, and system observations. The 17 areas assessed in the BASE review include:

1.   Establish written Security Programs and Emergency Management Plans.

2.   Define roles and responsibilities for security and emergency management.

3.   Ensure operations and maintenance supervisors and managers are held accountable for security issues under their control.

4.   Coordinate Security and Emergency Management plans with local and regional agencies.

5.   Establish and maintain a Security and Emergency Training program.

6.   Establish plans and protocols to responds to the DHS Homeland Security Advisory System (HSAS) threat levels.

7.   Implement and reinforce a Public Security and Emergency Awareness Program.

8.   Conduct tabletop and functional drills.

9.   Establish and use a risk management process to assess and manage threats, vulnerabilities and consequences.

10.   Establish and use an information sharing process for threat and intelligence information.

11.   Establish and use a reporting process for suspicious activity (internal and external).

12.   Control access to security critical facilities with ID badges for all visitors, employees, and contractors.

13.   Conduct physical security inspections.

14.   Conduct background investigations of employees and contractors.

15.   Control access to documents and security-critical systems and facilities.

16.   Ensure existence of a process for handling and access to Sensitive Security Information (SSI).

17.   Conduct Security Program audits.

Mr. Roe noted that, in general, the public transportation industry is making great strides in enhancing its security posture. The BASE reviews show that rail transit agencies covered by 49 CFR Part 659 are generally meeting the rule's basic requirements. In addition, transit agencies are coordinating security and emergency preparedness activities locally and regionally. Mr. Roe noted that the high level of participation of the Top 50 transit agencies in their local and regional emergency planning processes has been one of the most impressive overall findings of the BASE reviews. Mr. Roe also stated that results from the BASE reviews indicate that the transit industry is identifying critical assets and that risk and vulnerability assessments are being completed.

Mr. Roe then provided an aggregate analysis of the results from the 44 BASE reviews conducted to date. This presentation showed the average scores of the transit industry for each of the 17 recommended measures assessed through the BASE checklist. Mr. Roe explained, that based on these reviews, TSA has learned that the transit industry is struggling most in addressing the following issues:

• Security and Emergency Training Programs: For training, Mr. Roe noted that, while initial security training rated well in the BASE review, follow-up refresher training was lacking. Also, Mr. Roe pointed out that annual advanced, job specific training should be given to address security threats that may be encountered in a particular position (i.e., maintenance employee vs. bus operators), but this training is not commonly provided at the Top 50 transit agencies. Mr. Roe also reported that while emergency drills and exercises are taking place, the Top 50 transit agencies must improve upon how they are incorporating of the results of these exercises and drills into security plans, procedures, and training programs. Finally, Mr. Roe noted that the level of emergency response training for transit employees, including training on the National Incident Management System (NIMS), is in need of improvement.
• Public Security and Emergency Awareness Programs: Mr. Roe noted that many transit agencies have developed and implemented a public security and emergency awareness program (through Transit Watch and other activities). Mr. Roe also pointed out that many transit agencies are integrating randomness and unpredictability into their agencies are not including general awareness messages in public announcements in stations and vehicles. Also, many of the Top 50 transit agencies are not urging passengers to report suspicious people and packages to transit agency employees or through a designated phone number of email message system. Finally, Mr. Roe noted that only a few transit agencies in the Top 50 are conducting volunteer training programs for non-employees to aid in emergencies or evacuations, equivalent to the Citizen Corp program.
• Access Control: Mr. Roe noted that the industry has basic measures in place for securing critical infrastructure, but needs to take a hard look at improvements. For example, Mr. Roe noted that while most agencies have keyed locks for restricted areas, in many cases, access to these keys is not controlled. Also, most of the Top 50 transit agencies do not have back-up facilities to support critical operating functions, nor are they providing sufficient protective measures for underground/water assets at access points. Also, Mr. Roe noted that many transit agencies have not developed procedures for enhancing access control under heightened threat conditions. For example, transit agencies may not have written protocols for inspections of rights-of-way and facilities corresponding to orange and red Homeland Security Advisory System (HSAS) threat levels. Also, transit agencies may not have provided training and/or instruction focused on job function regarding the incremental activities to be performed by employees to ensure access control at heightened HSAS threat levels.
• SSI Programs: Mr. Roe noted that the Top 50 transit agencies are not conducting background checks on contractors and other non-employees with access to SSI materials and to critical facilities and infrastructure as frequently as they should. Mr. Roe also pointed out that many of the Top 50 transit agencies do not have formal policies in place for identifying and controlling the distribution of and access to documents it considers to be security sensitive, nor do they have formal policies in place for proper handling, control, and storage of documents labeled as or otherwise determined to be SSI pursuant to 49 CFR Part 15 or 1520. Finally, Mr. Roe explained that training on proper labeling, handling, dissemination, and storage of SSI (such as through the TSA on-line SSI training program) is not widely delivered at the Top 50 transit agencies. Mr. Roe stated that these findings generally support the need for the TSA 's SSI rule, which will clarify and extend the protection afforded to SSI materials in the industry and further identify covered persons and their responsibilities.
• Security Auditing: Mr. Roe noted that while basic programs are in place at many transit agencies, detailed auditing procedures, checklists, and reviews are not conducted as frequently as TSA would recommend. Further, the BASE reviews shows that transit agencies with more detailed and comprehensive security plans are having great difficulty in ensuring that all elements of these plans are being addressed. However, in spite of this situation, Mr. Roe noted that rail transit modes generally scored much higher on the BASE reviews than bus-only modes.

After this discussion of the weaknesses identified by the BASE reviews at the Top 50 transit agencies, Mr. Roe then identified some of the best practices observed by TSA during these reviews. Mr. Roe noted that over 50 such practices have been observed by TSA, including the following:

• WMATA's performance of high-intensity inspections that involve random saturations of a rail station with Transit Police, canine teams and other agency personnel to look for suspicious behavior and inspect trains as they stop at stations. WMATA has a similar program for its bus system.
• Maryland Transit Administration's use of Security Surges to performed zone- enforced unified sweeps (ZEUS), which serve as an unannounced, random, highly-visible show of force at locations throughout MTA's systems employing multiple law enforcement disciplines.
• Milwaukee Transit's development and distribution of a Threat and Countermeasures Pocket Guide, which provides guidance to transit employees on dealing with different threats and appropriate countermeasures in a convenient pocket-sized booklet.
• Minneapolis Metro's use of targeted patrols during heightened threats, which are performed in partnership with local police to provide an increased presence on trains traveling into and out of more heavily trafficked stations during periods of heightened threat.
• Chicago Metra's Security and Emergency Response Seminars for local law enforcement, fire departments, and emergency managers to review its security and emergency response programs, increase regional situational awareness, and enhance the effectiveness of interagency communications.
• Alameda-Contra Costa Transit's use of silent alarms with GPS that can be activated by bus drivers to send a GPS alert to the operations control center pinpointing the location and direction of travel of the bus for enhanced response by local law enforcement.
• San Diego Trolley's use of enhanced video surveillance, which uses an upgraded camera infrastructure at the San Ysidro station at the international border, employing smart video technology, exception-based monitoring, and alert notification to trigger security response.
• New Jersey Transit's system for employee background checks, which includes county, local, and Federal record checks, state driving records, verification of Social Security, state residency, and ten year employment and education history.
• CTA's Transit Alert Network that establishes communications and information sharing between the city's transit agencies; local, state, and Federal agencies; and the Surface/Public Transportation Information Sharing and Analysis Center. Also, CTA's Local Law Enforcement Training and Support Program, which enabled the Chicago Police Department to integrate with and effectively augment area transit capabilities with a Special Operations Section of 150 personnel trained in counter-terrorism, CTA's rail safety program, and HAZMAT response, with necessary protective equipment.
• EPTA's Interoperable Communications, which provides a state of the art system which enables communications between many types of dissimilar systems including radios, telephones, computers and cell phones. The system currently integrates 25 outside participating agencies in the region in a consolidated security network for threat and incident response and other emergencies.
• New York MTA's Employee and Public Awareness "See Something, Say Something" campaign, which was jointly developed by MTA's Office of Safety and Security and the NYPD Interagency Counterterrorism Task Force. The campaign provides a toll-free reporting number that enables rapid response and tracking of security reports for trend and pattern analysis. The program was recently expanded to television in the New York Metropolitan area.
• BART's Terrorism Response Guide, which is a controlled document that fully describes required and optional activities for implementation based on changes in the HSAS threat level. Appropriate guidance is provided to system employees on easily carried and retrieved cards detailing response actions, particularly for chemical and biological events. The guide also enables front-line employees to take effective steps to prevent harm or mitigate consequences.
• Houston Metro's Integrated Security Oversight program that includes a proactive Security & Breach Review Committee composed of Vice Presidents or their designees from across the agency's operational and staff divisions. The committee elevates prevention and response capabilities through proactive engagement and acts in an advisory capacity to review incidents - both internal and in other systems - to correct deficiencies and identify areas of concern before they adversely affect security.
• Long Beach Transit Authority's Coordinated Deterrence program, which includes the 13 law enforcement jurisdictions in which the system operates to ensure unrestricted prevention and response activities. Transit enforcement and Long Beach Police Department are trained in surveillance and counter-surveillance measures, and random sweeps of areas of security concern are identified through intelligence or law enforcement briefings and random bus boardings as part of community policing effort.

Mr. Roe concluded his presentation by reiterating that the BASE program serves as a valuable tool in supporting and strengthening transit security through identification of security program gaps or weaknesses; the collection of security program data to establish national baselines; the provision of data to support security program refinement; the provision of current security specific data to support Federal grant and program development decisions; and the reduction of occurrence of duplicative audits focused on individual programs.

SSO and Rail Transit Agency Response

During the question-and-answer period after his presentation, Mr. Roe was asked if the BASE review could be used during the New Starts process to improve security. Mr. Roe responded by recommending that the BASE review process be used at project onset and encouraged project personnel to contact their local TSA regional offices to request that a BASE review be performed during this project phase. Mr. Roe noted that, because of the New Start process, the BASE review checklist would need to be modified to be more applicable to a New Starts project in the preliminary stages of design versus its existing format, which is directed towards existing systems in operation.

Mr. Roe was next asked where he thought the responsibility for system security should reside in an organization's structure. He responded that placement may not be as important as the authority given to the security function. While some agencies establish a direct reporting relationship between top management and the security functions, others do not. Both have their benefits; however, what is most important is if the security function has the appropriate level of authority and responsibility to fulfill its functions. Mr. McElveen interjected that the FTA is seeing that the transit industry is beginning to create executive management level positions for both safety and security.

Mr. Roe also responded to a question pertaining to the security directives that have been established by TSA , stating that TSA is moving away from these directives and that Tom Farmer, in his presentation, would provide additional detail on the future role of TSA regulation in the rail transit industry. However, if participants wanted copies of these directives, Mr. Roe urged them to contact their TSA regional offices.

New TSA Legislative Authorities

Mr. Gerhart then introduced Mr. Thomas Farmer, Deputy General Manager, Mass Transit, TSA . Mr. Farmer also used a New York Mets baseball story to kick-off his session. Mr. Farmer then presented an overview of the new legislation that has been enacted to implement the recommendations of the 9/11 Commission Act of 2007, Public Law 110-53.

Mr. Farmer began by stating that the President Bush signed this act on August 3, 2007 and that it was a culmination of concerted efforts initiated from the outset of the 110th Congress. Two former House bills - HR 1, Implementing the 9/11 Commission Recommendations Act, and HR 1401, Rail and Public Transportation Security Act; and a former Senate bill - S4, Improving America's Security Act - were the forerunners to the Act.

A joint conference committee was created and used to resolve differences and to produce the legislation as enacted during July 2007. The comprehensive homeland security legislation provisions encompass a broad spectrum of subjects including intelligence, education and training, information sharing, transportation security, and the spread of democratic freedoms. Mr. Farmer pointed out that sections of most interest to public transportation are Titles XII through XV, including:

• Title XII - information sharing for homeland security
• Title XIII - transportation security support
• Title XIV - public transportation security
• Title XV - rail security

Mr. Farmer went on to state that the focus of TSA is currently in three areas: security grant authorizations, security support programs, and regulatory and security program mandates. Through the security grant authorization program, the Federal government has authorized $650 million in FY 2008 for public transportation. This authorization will increase to $1.1 billion by FY 2012.

For railroad transportation including passenger and freight operations, security grants have been authorized for $448 million in FY 2008. This authorization will increase to $508 million by FY 2012.

In addition, Amtrak has received grants to make security improvements to tunnels located in the Northeast Corridor. The focus of these improvements will be on tunnels used for passenger rail service in the Washington DC, Baltimore, and New York/New Jersey areas. Grants have also been authorized to improve Amtrak fire and life safety.

Mr. Farmer also stated that specific programs or protections have been authorized to support security enhancement activities through various means. These include:

• Surface Transportation Security Inspection Program - which authorizes mission, authority, and activities of TSA surface inspectors, and may be used in all surface modes of transportation. Program expansion is also planned with 100 inspectors in FY 07, planned to grow to as many as 200 by FY 10.
• Visible Intermodal Prevention and Response Program - DHS , through TSA , is authorized to employ VIPR teams to augment security in surface transportation modes. These teams consist of mixed forces of Federal Air Marshals, Transportation Security Inspectors, Transportation Security Officers, Explosives Detection canine Teams, and screening equipment. Coordination with systems and law enforcement will be required.
• DHS Funding of Information Sharing and Analysis Center - $650,000 in FY 08, FY 09, and FY 10.
• Protection from Liability - to ensure good faith reporting of suspicious activity.
• Whistleblower Protection - public transportation and rail employees and contractors.
• Civil Administrative Enforcement Authority - which extends TSA 's authority to employ civil administrative procedures for compliance with security requirements to surface modes. It also resolves gaps in the Aviation and Transportation Security Act, and provides a written notice and opportunity to respond expressly accorded to public transportation agencies.

Next, Mr. Farmer briefly discussed the various program and regulatory mandates established by the legislation. These include:

Program Mandates: In the next year, TSA will be responsible for developing legislation to implement the following program mandates:

• National Strategy for Public Transportation Security
• National Strategy for Rail Transportation Security
• National Information Sharing Plan
• National Public Awareness Program
• National Exercise Program
• Security Grant Program
• Security Assessments - grant eligibility for public transportation agencies tied to DHS completion of security assessment
• Name-based checks - public transportation and rail frontline employees
  • Terrorist Watch List and Immigration Status

Regulatory Mandates: In the next year, TSA will be responsible for developing regulations to implement the following requirements:

• Risk-Based Tiers to manage the Transit Security Grant Program
• Security Plan Requirements
• Security Training Requirements for Frontline Employees
• Security Assessment Requirements

Mr. Farmer concluded his presentation by taking questions from the audience.

SSO and Rail Transit Agency Response

Mr. Farmer was asked if funding would be made available to SSO agencies through TSA to meet the TSA security requirements. Mr. Farmer responded that funding through the TSA for this purpose would be unlikely.

Mr. Farmer was also asked for practical methods that could be used to verify System Security Plan (SSP) implementation. He responded that the SSO agencies should:

• Go out to the transit agency and observe operations;
• Use flash cards and graphic instructions;
• Implement an efficiency testing program;
• Perform surprise operator visits and ride-alongs; and
• Track advisories, stop orders and ride along findings.

Mr. Farmer stated that the BASE assessments are being used to develop the key areas of legislation and further explained the mandates that have been made, which TSA must now implement and follow. Among these, TSA has been directed to perform name-based checks of front-line transit employees against terrorism watch lists. Discussion of the potential legal constraints that may be experienced with implementing such a program then ensued, and Mr. Farmer was asked if the TSA had identified a case that would be going through the legal system to assure there will be no law suits if rail transit agencies follow this program. Mr. Farmer responded that no such case has been identified at this time.

Following this question, Mr. Farmer was asked why the Commercial Drivers License (CDL) certification process could not be used to perform the same type of name-based checks since it addresses much of the same information and is more specific to individuals using social security numbers than simply using names. Mr. Farmer responded that he agreed with this approach and stated that TSA will likely follow the CDL example however a final decision has not yet been made.

Mr. Farmer was next asked what he felt was the best security strategy for rail transit systems. He responded that TSA recommends that each rail system assume that it is being monitored and watched at all times and that they use active deterrents to prevent terrorist activity.

Finally, Mr. Farmer was asked to provide clarification regarding what TSA grant money could be used for. He stated that it could not be used for training of non-rail transit agency personnel and that paratransit systems have not been considered to date. He also clarified that the costs incurred by a rail transit agency to back-fill an employee's position while he/she is attending training is an eligible expense that can be recouped through the grant program.

DAY THREE, WEDNESDAY, SEPTEMBER 19, 2007

9. SPECIAL TRAINING SESSIONS

The Wednesday morning session of the 11th Annual SSO Meeting began with a brief introduction by Mr. McElveen, who reviewed the day's agenda. Following this introduction, the attendees broke into two groups. Rail transit agency representatives participated in a session led by Dr. Beverly Sauer, Professor of the Practice-Managerial Communication, McDonough School of Business, Georgetown University. SSO agency representatives attended a separate session to review the SSO Program Managers Training Curriculum, and to discuss other issues in the SSO Program.

a. Rail Transit Agencies

Dr. Sauer's presentation "Risk Communication: Making the Case for Safety in Presentations, Reports, and Meetings" discussed the importance of communicating clearly with top management to effectively implement safety recommendations. Dr. Sauer stated that the goal of her training session was to provide the rail transit agency participants with the knowledge and skill needed to improve the communication aspects of hazard assessment, risk management, accident investigation and safety; to enhance rail transit agency responsiveness to the implementation of Part 659; and to help the rail transit agencies improve local day-to-day documentation and system safety communication in their organizations.

Dr. Sauer stated that rail transit agencies must work cooperatively with SSO Program Managers and others to implement Part 659 and, in some cases, must partner with more powerful departments to resolve safety and security issues. Rail transit agencies also need specific instruction to help them develop the SSPP and status reports on accident investigations and corrective action plans. Dr. Sauer highlighted that this must be accomplished with limited staff resources and other day-to-day demands.

Dr. Sauer explained that strong legal authority does not automatically confer respect, appreciation, or a willingness to partner. Technical experts must therefore design and deliver information to audiences who do not always share the same knowledge, education, experience, or authority. This requires the technical experts to shift their stance from "technical observers" to "active persuaders."

Dr. Sauer pointed out that many safety directors report to different levels within their organizations and are sometimes three to five management levels removed from the General Manager. As a result of these organizational challenges, other departments may not implement required safety actions, or they may take actions of their own without informing the safety directors. Other technical issues are also faced by the rail transit agencies, along with interorganizational challenges. For example, SSO enforcement efforts may initially be directed at the wrong level, the safety director may not have the authority or resources to address needed actions, SSO Program Managers may not have the authority or support to engage rail transit agency executive leadership, and resistance to change may prevent effective implementation of corrective actions at the agency.

Dr. Sauer pointed out that each of these challenges actually indicates a larger problem for the agency, which is a failure to effectively communicate. In many instances, agencies allow technical details to obscure the seriousness of problems and too often there is no clear metric for evaluating the significance of observations, inspection reports, and analyses. Scientific observations, findings, and analyses fail to convey the imminence of a situation and do not persuade management.

There is also often a lack of transparency and accountability in the communications of a rail transit agency. Data reports and field visits may provide conflicting data; agencies may be concerned with legal issues and potential liabilities; multiple priorities must be managed causing safety to become lost; and different levels of personnel may have different perceptions of safety and their responsibilities for providing safety.

Dr. Sauer reasoned that the rail transit industry faces these challenges and problems because most engineers and safety managers are meticulous and detail oriented, and have been trained to communicate in a very technical manner that is not clear or effective for communicating with management.

Building on these premises, Dr. Sauer used the Columbia space shuttle accident as an example of how poor communication had a direct impact in causing the accident. Speculation and informal communication in NASA emails showed that during the Columbia crisis, disaster response was slowed. As a result NASA began training individuals to distinguish patterns of discourse appropriate to collaboration, information, face-to-face inspections, research and development, and crisis risk decision-making as an ongoing process of research and development work.

Dr. Sauer next presented the Sago Mining disaster as an example of how automated systems of authority impacted the disaster response. Dr. Sauer posed the questions "if we give workers the decision making power as authorized persons, what are their liabilities when the systems fail?" She explained that in the Sago Mining disaster, these automated systems exposed tensions between old and new narrative identities, which required new training and communication practices that was never provided. To manage the risks presented by automated systems of communication, the organization must account for embodied experience, and consider the relationships between "clock time" and "relative time," as well as the human dimensions of automated control.

Dr. Sauer recommended that individuals and managers be trained to contextualize and assess detail for specific audiences. She also recommended that documentation tracking systems be used to insure follow through in communication. She cautioned that specifications of language obscure the distinction between future plans and real time implementation and that Passive sentence structures obscure individual accountability. To combat these problems, individuals should be trained to recognize operational descriptive and functional discourses, and to use active sentence structure to put accountability back into safety communications.

Dr. Sauer next discussed how to persuade audiences through effective communications, noting that stakeholders should be defined and communications should build on what these stakeholders know and understand. Dr. Sauer concluded her presentation by presenting a few techniques for communicating more effectively, including:

• Using rhetoric to structure a convincing argument;
• Advancing claims and warrants;
• Using metaphors and shared history to make technical arguments accessible;
• Targeting the needs of the audience;
• Building buy-in by appealing to shared concerns; and
• Relating safety concerns to other needs and interests at the agency.

SSO Agencies

Ms. Boyd presented FTA's SSO Program Managers Training Program Curriculum, by first providing the SSO representatives with a brief background of the curriculum and how it was developed. In July, 2006, the Government Accountability Office (GAO) recommended that the FTA Administrator assess whether oversight agency personnel were receiving adequate amounts of training to perform their activities effectively. The GAO recommended that FTA develop an official training curriculum and provide guidance for State oversight agencies, and the provision of FTA resources, if feasible, to support SSO Program Managers in completing the training curriculum.

Ms. Boyd noted that FTA responded to this recommendation by developing a draft training curriculum, which was discussed at the 2nd Annual SSO Program Managers Meeting held in Tampa, FL May 7 - 10, 2007, and in August 2007, began developing Individualized Training Plans (ITPs) for SSO Program Managers. FTA also began allocating resources to fund the SSO Program Manager's training through the Transit Safety Institute (TSI).

Ms. Boyd explained that following the presentation of the SSO Program Managers Training Curriculum in Tampa, FL, FTA distributed the 2007 SSO Program Managers Training Survey. SSO Program Managers were asked to complete the survey, providing FTA with a snapshot of SSO Program Manager training received to date as well as input regarding the usefulness of a wide range of training courses and topics. FTA used the data gathered from the SSO Program Managers Training Survey to further tailor the curriculum to fit SSO Program Managers' needs.

Of the types of training methods available (i.e., workshops, lectures, panel sessions, facilitated structured discussions, facilitated free discussions, case studies, self study, and computer based training), respondents felt that workshops, lectures and case studies were the most helpful. SSO Program Managers were also asked to assess the extent to which they felt they had received a satisfactory amount and quality of training in several key areas. The responses received are provided below.

To gather data on the amount of budgetary allocations available for training, SSO Program Managers were asked to provide information pertaining to the training budgets of their respective agencies. The training budgets of each SSO agency varied greatly and in several cases were unknown. Of the 26 responses received, nearly half stated that they received $2,500 or less annually to attend training.

When asked how many times per year they would be able to participate in workshops and training sessions lasting between three and five days, 5 of the 31 SSO Program Managers responded that they would be able to attend once per year, 13 responded that they would be able to attend twice per year, 9 responded that they would be able to attend three times per year, and 4 responded that they would be able to attend training of this length, four or more times per year.

Attendees were finally asked to indicate the level of training they would like to receive (i.e., introductory, advanced, update/refresher, or none) pertaining to FTA's SSO Program and the degree of importance for which they felt the training was necessary. Responses indicate that of the training topics provided, an introductory level of training is desired most strongly for establishing program performance measures for SSO Programs, implementing the hazard management process, and three-year safety and security review conduct. An advanced level of training is most strongly desired for SSPP review and corrective action plan management; and a refresher level of training is most strongly desired for SSO administrative procedures.

Training topics considered to be most important included review of the internal safety/security audit process, Three-Year Safety/Security Review conduct, Program Standard development, Security Plan review, SSPP review, and investigation report review.

After reviewing the survey results, Ms. Boyd explained that the survey results helped to clarify the needs of the SSO community and to develop the ITPs for each SSO Program Manager. The ITPs are being built around the following three training tiers:

• Tier 1: Ongoing Oversight Effectiveness Training - Annual FTA meetings and workshops and training available at the rail transit agencies. This includes Annual FTA Invitational Workshops for SSO Program Managers, typically held in the spring; specific sessions for SSO Program Managers during FTA's Annual SSO Program meeting, typically held in the fall; and training at rail transit agencies regarding ROW safety, accident investigation, operators and supervisors training, or other related topics.
• Tier 2: Rail Transit Safety and Security Subject-Matter Training and Certification - Completion of five core TSI courses and receipt of World Safety Organization (WSO) Certificate. The five TSI courses include:
  • Transit Rail System Safety (FT00543)
  • Transit System Security (FT00432)
  • Transit Industrial Safety Management (FT00457)
  • Transit Rail Incident Investigation (FT00430)
  • Effectively Managing Transit Emergencies (FT00456)
• Tier 3: Advanced Subject-Matter Training and Professional Safety Certification - Includes other TSI and National Transit Institute (NTI ) training, as well as NTSB Training Academy, FRA sponsored and approved training, American Society of Safety Engineers (ASSE) Safety Program Manager training and certificates including pursuit of Certified Safety Professional (CSP) credential from the Board of Certified Safety Professionals.

Ms. Boyd further explained that FTA is committed to partnering with State agencies to ensure that sufficient resources are available to support SSO Program Manager training. Each ITP will cover the period FY 2008 through FY 2010, and will be developed in consultation with each SSO Program Manager to address Tier 1 and Tier 2 training needs. FTA began contacting SSO Program Managers in August, and so far almost all SSO Program Managers have been scheduled for training through their ITPs.

In each ITP, FTA will identify training costs to be covered by FTA and propose training costs to be covered by the SSO Program Manager's organization. FTA will also track the progress of each SSO Program Manager in receiving this training over the three-year period, and will continue to follow up with his or her supervisor regarding the status of the training plan in semiannual correspondence.

Completed ITPs will be transmitted to each SSO Program Manager's immediate supervisor, soliciting support in the provision of resources to ensure that the SSO Program Manager receives the identified training during the specified three-year period. FTA's Administrator will also send a "Dear Colleague" letter to enhance awareness and request support in implementing the SSO Program Managers Training Curriculum.

Ms. Boyd went on to state that over the three-year period between October 1, 2007 to September 30, 2010, FTA anticipates being able to cover training costs for no less than three core courses. During Fiscal Year 2008 (October 1, 2007 to September 30, 2008), FTA will provide each SSO Program Manager with funds - to be administered by TSI - to attend two of the following core courses: Transit Rail System Safety (FT00543), Transit System Security (FT00432), Transit Industrial Safety Management (FT00457), and Effectively Managing Transit Emergencies (FT00456).

By September 30, 2010, FTA is committed to ensuring that each SSO Program Manager has applied for two (2) certificates - TSI Rail Transit Safety and Security Certificate, and WSO Rail Transportation Safety Certification. TSI awards its Rail Transit Safety and Security Certificate to individuals who have successfully completed four of the five core courses in a consecutive three-year period. Additional information on the TSI Rail Transit Safety and Security Certificate is available at: http://www.tsi.dot.gov/divisions/Transit/TSSP.aspx or by calling TSI at (405) 954- 3682. As part of each SSO Program Manager's ITP, representatives from FTA's Office of Safety and Security will identify key application deadlines and requirements.

In partnership with TSI , the WSO has established two certification categories for the rail transportation industry - Certified Safety Specialist and Certified Safety and Security Director. To be designated as a Certified Safety Specialist, an individual must have successfully completed the five core courses (or have received equivalencies from TSI ) and have a minimum of five (5) years of directly related safety experience in the rail transportation industry. To receive the Certified Safety and Security Director (CSSD) designation, an individual must have successfully completed the five core courses (or have received equivalencies from TSI ) and have a minimum of ten (10) years of directly related safety experience in the rail transportation industry. Additional information on this certificate program can be obtained from WSO World Management Center, 106 W. Younger Ave, Suite G, P.O. Box 518, Warrensburg, MO 64093, Telephone: (660)747-3132, URL: http://www.worldsafety.org/, E-mail: wsowme@socket.net.

Ms. Boyd then introduced Ms. Radonna Snider, Program Analyst with TSI , who walked the SSO Program Managers through the travel process to be used in filing their travel forms. Ms. Snider also distributed TSI 's Travel Brochure, which was developed to explain this process to the SSO Program Managers.

Key steps in this process include the following:

Ms. Snider noted that she was available to support any SSO Program Manager with questions regarding this process. Her contact information is:

Ms. Radonna L. Snider

Program Analyst

U.S. Department of Transportation

Transportation Safety Institute

P.O. Box 25082, DTI-80

Oklahoma City, OK 73125-9967

Phone: (405) 954-4799

Fax: (405) 954-0367

Email: radonna_snider@tsi.jccbi.gov

Mr. Richard Wong, FTA Legal Counsel, then spoke in general terms about the NTSB recommendations and the reauthorization of SAFETA-LU. Mr. Wong explained FTA's current legal position, and noted that additional enforcement authorities for SSO agencies, or direct FTA funding to the States, would require additional delegations of authority from Congress to FTA. Mr. Wong also urged SSO Program Managers to work with their State agencies and lobbying entities and with the American Association of State Highway and Transportation Officials (AASHTO) to place their needs before members of the House Transportation and Infrastructure Committee and its Chairman, James Oberstar.

Following Mr. Wong's remarks, Mr. Taborn led a group discussion pertaining to the NTSB's findings and recommendations from the CTA derailment investigation and the new authorities provided to TSA in H.R. 1 and their potential impacts on the SSO program. The following issues were discussed:

• The SSO Role in Security: Several SSO Program Managers were concerned by TSA 's focus on terrorism prevention and preparedness. While many SSO Program Managers stated that they did not mind turning Part 659 security requirements over to TSA , they expressed some trepidation over the fact that crime prevention and general emergency preparedness issues did not seem to be high on the TSA agenda. They questioned why TSA would not want to incorporate crime prevention and general emergency preparedness as cornerstones of its transit security program. Mr. Taborn explained that these details are still being worked out. He noted; however, that it is entirely possible that SSO agencies may retain some security oversight role for the rail transit agency's crime prevention and management programs, while TSA would focus more directly on terrorism-related issues. Mr. Taborn noted that FTA would keep the SSO Program Managers informed regarding the rulemaking processes being implemented by TSA , as well as the results of the partnership initiative to implement H.R. 1 requirements.
• Growing Disconnect between Safety and Security: There was also discussion regarding a trend noted by some SSO Program Managers at the rail transit agencies in their jurisdictions to separate safety and security, even though, in the past, the two departments had been working closely together. With separate funding streams and separate programs, some SSO Program Managers were worried that their safety departments were being cut out of critical planning and emergency exercising functions.
• Recommendations for Conducting Three-Year Safety Reviews: Building on discussions from Tuesday's sessions, several SSO Program Managers expressed their concerns regarding how to approach the Three-Year Safety Review. There was discussion regarding the best way in which to verify SSPP implementation, as well as how to make recommendations and track them. FTA noted that it hopes to provide guidance, in the form of a clarification letter, in the near future. Ms. Boyd also handed out an excerpt from FTA's Resource Toolkit for State Oversight Agencies Implementing 49 CFR Part 659, to refresh everyone on the current FTA guidance. There was also a brief discussion of ways in which SSO agencies could coordinate with the rail transit agency safety departments to support verification of maintenance functions and rules compliance programs. Several SSO Program Managers noted that the General Managers at their rail transit agencies were somewhat uncomfortable signing the annual certification of SSPP implementation based on the internal safety audit process. A few SSO Program Managers felt that closer coordination between the rail transit agency internal safety audit process and the SSO Three-Year Safety Review would offer considerable benefits in obtaining a more accurate picture of SSPP implementation.

10. Tour of Metro Transit Light Rail System

After breaking for lunch, the group reconvened in the hotel lobby and boarded two Metro Transit articulated buses, which transported the meeting attendees to Metro Transit's Light Rail System Maintenance Facility and Control Center. The tour of this facility was organized and coordinated by Mr. Mike Conlon and Mr. John MacQueen of Metro Transit's Safety Department.

In route to the facility, Mr. Conlon and Mr. MacQueen arranged for the group to drive by the site of the Minneapolis bridge collapse, which occurred August 1, 2007. The accident site served as a poignant reminder of the current state of the nation's roadway infrastructure system and how catastrophic accidents can happen so quickly and without warning. Once at the maintenance facility, the participants broke into several groups, which were each led on tours of the facility including the maintenance shops, control center, and power substation. A brief presentation was also delivered by Mr. MacQueen, pertaining to the agency's track worker protection and inspection training programs.

Mr. MacQueen noted that the types of work performed on the Metro Transit ROW include:

• Walking track inspections and maintenance,
• Signal and switch inspections and maintenance,
• OCS inspections and maintenance, and
• Contractor work.

Mr. MacQueen stated that regardless of the type of work being performed, training is required. All employees and contractors that will be working within 12 feet of track center must take a 1-hour On-Track Safety training class. All Metro Transit rail employees working in operations or maintenance must be "rules qualified" and must be recertified on those rules annually.

Mr. MacQueen explained that the methods of track protection used at Metro Transit depend on the type of work being performed. Before work begins, a determination must be made as to whether or not the work is routine inspection, if it involves maintenance, if tools will be used, how it will impact train service, and if the track needs to be taken out of service. Depending on the answers to these questions, employees can use five different methods for protecting the track. These include:

• Self protection,
• Use of a Designated Look Out,
• Implementation of Temporary Restricted Zones ("Line 5"),
• Use of Work Zones (Movement Coordinator),
• Track out of Service (Employee in Charge).

Self protection is allowed if the work does not require the use of tools. It is generally for minor inspection or observation of the track. Use of a designated lookout is preferred to individual protection. To use a designated lookout, the work being performed must be of a nature that it can be immediately interrupted so that the crew can clear the track and a passing train can operate through the work area without risk. One person remains focused on train movements at all times and alerts the crew of approaching movements.

Mr. MacQueen next explained the "Line 5" rule and stated that it is used to temporarily restrict a work zone. It requires the use of Track Warrant and can be used at the discretion of the RCC Supervisor as a form of protection for workers in lieu of a work zone. Such usage is limited to locations where trains have clear visibility of the restricted area, and the work performed does not hinder the ability to hear an approaching train, and the work group is able to clear prior to arrival of the train. It may also be used specifically to protect activity along the ROW that may unexpectedly encroach on the ROW , or for switch inspection or other stationary inspections. Mr. MacQueen stressed that it cannot be used to protect transit workers in or near tunnels, or on or near flyovers, with the exception of Lake Street Station within ten feet outside of the railroad signals.

When Line 5 is used, a temporary sign is set to designate a temporary speed restriction. When issued, trains or other track equipment must pass through the stated limits at restricted speed until the rear of the consist is past the restricted zone (rear end restriction) and must look out for persons or equipment in the ROW . The Train Operator is ultimately responsible for the safety of workers when Line 5 is used.

Mr. MacQueen next explained that a movement coordinator is in charge of a work zone. The work zones allow movement of trains through the area only with permission of the movement coordinator. The movement coordinator performs no other work than controlling train movements and ensuring that workers are clear of the track when necessary. This person may or may not be a foreman, but regardless of who holds this role, he/she cannot perform any other work until the job is complete.

The final type of track protection discussed by Mr. MacQueen was "Employee in Charge" protection. This type of protection can be used only when the track is out of service. Therefore there are no train movements in the area. The Employee in Charge is responsible for obtaining permission to occupy the track and is responsible for ensuring all workers and equipment are clear before putting the track back in service. Because there are no train movements in the area, the Employee in Charge is able to perform other tasks while holding this role.

Mr. MacQueen stated that Metro Transit does operate through a tunnel, and that work can only be performed in these locations if the track is taken out of service, or if a work zone has been established. When in the tunnel, track workers must call the RCC to state if they are in the clear. This can only be done if they are inside a cross passage and is not allowed if they are on the walkway.

Mr. MacQueen stressed that communication is the key to a successful track worker protection program. Prior to performing any task requiring the coordination of two or more employees, the employees involved in the job must hold a "job briefing" to insure all have a clear understanding of the task to be performed and their individual responsibilities. The job briefing discusses:

• The specific job(s) to be done or move(s) to be made,
• The responsibility of each employee,
• Any additional instructions due to an unusual situation,
• Any specific safety reminder due to a hazardous condition or unusual practice,

If necessary, an additional briefing is held as the work progresses or the situation changes.

Mr. MacQueen stated that to get the most out of their track worker protection program, they investigate all close calls and try to improve rules and procedures to prevent recurrences. They also retrain employees as necessary. They also try to learn from other agencies.

When WMATA began having track worker safety problems, Metro Transit took its existing protocols and added an additional requirement that track inspectors make a radio statement to the RCC of walking track inspections. Inspectors state the stations they are in between and in what direction they are moving. Walking track inspectors are also required to report to RCC via radio when they pass fixed locations such as stations. The RCC updates train operators of the locations passed by walking track inspectors. The train operators are then required to pass walking track inspectors at restricted speed.

Mr. MacQueen concluded his presentation by reiterating that "safety is everyone's" responsibility. Following Mr. MacQueen's presentation and the tour of Metro Transit's facilities, the group boarded a light rail train which transported the group to the Mall of America for dinner. This trip enabled participants to become better acquainted with Metro Transit's Light Rail System, vehicles, and stations.

DAY FOUR, THURSDAY, SEPTEMBER 20, 2007

11. SAFETY CREDENTIALS

The final day of the 11th Annual SSO Program Meeting began with two presentations regarding certifications available to rail transit safety and SSO personnel. Mr. Ronald Keele, Executive Director, Office of Safety and Risk Management, Maryland Transit Administration, explained the process for becoming a Certified Safety Professional (CSP). Ms. Elayne Berry, Executive Director of Safety and Quality Assurance, Metropolitan Atlanta Rapid Transit Authority (MARTA) discussed the benefits of becoming a Six Sigma Black Belt.

Certified Safety Professional

Mr. Keele began his presentation by explaining that there are several different certifications available to rail transit safety and SSO professionals. Perhaps the most common in the industry is the Professional Engineer (PE) designation. Other certifications include:

• CIH - Certified Industrial Hygienist
• ARM - Associate in Risk Management
• CHMM - Certified Hazardous Materials Manager
• EHS - Environmental Safety and Health Management Specialist

Mr. Keele explained that Certified Safety Professional (CSP) is the registered certification mark of the Board of Certified Safety Professionals (BCSP), established in 1969 and headquartered in Savoy, Illinois. BCSP also issues an ASP-Associate Safety Professional--certificate as a preliminary step to CSP status.

To qualify for the CSP , one must:

• Have either an associate degree in safety and health or a bachelor's degree in any field from an accredited college or university recognized by the Council for Higher Education Accreditation (CHEA) and/or the U.S. Department of Education. Experience alone cannot make up for the academic requirement.
• Have at least four years of acceptable professional safety practice. To be accepted, professional safety practice must meet all of the following requirements:
  • Be the primary function of a position.
  • The position's primary responsibility must be the prevention of harm to people, property and the environment.
  • The position must be full time.
  • The professional safety function must be at least 50% of the position duties.
  • Duties must be at a professional level, determined by the degree of responsible charge and the ability to defend and reliance by others on analysis and recommendations related to control of hazards.
  • Have a breadth of duties including hazard recognition, evaluation and analysis, and development and implementation of control.
• Pass the Safety Fundamentals and/or Comprehensive Practice examinations.

Mr. Keele explained that candidates who have successfully passed other exams through other acceptable certification and licensing programs, and who currently hold such certifications or licenses, may be granted a waiver from the Safety Fundamentals exam. Acceptable certifications and licenses include the Certified Industrial Hygienist (CIH), Certified Health Physicist, and Professional Engineer (PE) designations.

Mr. Keele then presented the following sample question to provide the audience with an example of the type of questions that will be faced on the Comprehensive Practice Exam.

• An excavation 18 feet deep, 16 feet wide at the bottom and 50 feet wide at the top was constructed to install a new piping duct bank. How many gallons of water will it hold if it is 1.07 miles long?

Mr. Keele revealed that the answer to this question is 24,833,382 gallons of water, and emphasized the difficulty of the exam.

Mr. Keele noted that to retain the Certified Safety Professional designation, a person who has met the requirements to achieve the CSP must:

• Pay an annual fee.
• Meet Continuance of Certification requirements every five years.

Mr. Keele observed that making the decision to pursue additional certifications is an individual choice. With a CSP , Mr. Keele pointed out that you can achieve a great deal of personal satisfaction by:

• Meeting a standard that is set and recognized by the profession, and
• Enhancing your image as a "credentialed" professional.

Mr. Keele also noted that the CSP credential is a recognized and highly credible designation for safety professionals. There are only 11,000 safety professionals with CSP s in the United States. Receiving such a designation allows you to elevate your status within the transit or oversight agency and increases your recognition among your peers as a competent safety professional. Receiving increased responsibility and increased pay within the organization is also a possibility. Mr. Keele also pointed out that becoming a CSP also improves the agency's image and instills a public confidence and level of assurance in the agency's performance.

Mr. Keele explained that he obtained his CSP when he worked for NASA. He joined NASA shortly after the Challenger accident, and, at the time, NASA encouraged all of its safety professionals to obtain CSP s, in part to restore public confidence in the agency.

For more information concerning the CSP certification, questions can be directed to the BCSP at: 208 Burwash Avenue, Savoy, IL 61874, Website: http://www.bcsp.org/, Telephone number: 217-359-9263.

Six Sigma Black Belt

Ms. Elayne Berry next discussed the benefits of becoming a Six Sigma Black Belt in the rail transit environment. Ms. Berry explained that Six Sigma is a disciplined, data-driven approach and methodology for eliminating defects (driving towards six standard deviations between the mean and the nearest specification limit) in any process -- from manufacturing to transactional and from product to service.

The statistical representation of Six Sigma describes quantitatively how a process is performing. To achieve Six Sigma, a process must not produce more than 3.4 defects per million opportunities. A Six Sigma defect is defined as anything outside of customer specifications. A Six Sigma opportunity is then the total quantity of chances for a defect. Process sigma can easily be calculated using a Six Sigma calculator.

The fundamental objective of the Six Sigma methodology is the implementation of a measurement-based strategy that focuses on process improvement and variation reduction through the application of Six Sigma improvement projects. This is accomplished through the use of two Six Sigma sub-methodologies: DMAIC and DMADV.

• The Six Sigma DMAIC process (define, measure, analyze, improve, control) is an improvement system for existing processes falling below specification and looking for incremental improvement.
• The Six Sigma DMADV process (define, measure, analyze, design, verify) is an improvement system used to develop new processes or products at Six Sigma quality levels. It can also be employed if a current process requires more than just incremental improvement.

Both Six Sigma processes are executed by Six Sigma Green Belts and Six Sigma Black Belts, and are overseen by Six Sigma Master Black Belts. According to the Six Sigma Academy, Black Belts save companies approximately $230,000 per project and can complete four to 6 projects per year. General Electric, one of the most successful companies implementing Six Sigma, has estimated benefits on the order of $10 billion during the first five years of implementation. GE first began Six Sigma in 1995 after Motorola and Allied Signal blazed the Six Sigma trail.

Ms. Berry noted that at MARTA, the Six Sigma approach is used to focus on key performance indicators as they relate to hazard management, accidents and incidents, and investigations. She further explained how MARTA has incorporated the Six Sigma belt designations into its professional development initiatives for staff. She stressed however, that before pursuing this designation, you should first indentify potential projects that can be used to gain the designation and evaluate the return on investment.

Ms. Berry next described the project she pursued to become a Six Sigma Black Belt. This project involved a bus fuel efficiency study that was performed to improve fleet miles per gallon in the operating environment, and to increase the ratio of fuel consumed for revenue service versus overhead. To complete the project, Ms. Berry used various analysis techniques including DMAIC, Cause and Effect Analysis of fuel consumption, SIPOC Diagramming, Process Ranking, Process Capability, and Feasibility Analysis. As a result of this project, MARTA was able to reduce the sources of variations in the fuel and fluid systems for revenue vehicles. It was also able to increase the correlation between actual miles driven and calculated miles per gallon (MPG); model fuel usage before and after the service change occurred to determine the impact and sources of variation on calculated MPG by fuel type to allow for increased efficiency; and reduce operating margins of fuel usage for the revenue fleet.

Ms. Berry explained that to obtain the Six Sigma Green Belt designation requires approximately three to six months. To become a Green Belt, Ms. Berry performed a study to improve reliability and reduce service interruptions by evaluating pre-in-service rail car inspections effectiveness in identifying defects prior to entering service. Other proposed Green Belt projects include:

• Reducing Fare Gate Malfunctions
  • Improve customer satisfaction
  • Reduce rework and labor costs
• Reducing Workplace Injuries
  • Reduce lost time injuries
  • Reduce workers' compensation claims
  • Reduce overtime (providing coverage during absence)
• Railcar Pre-Service Inspections
  • Improve MDBF/MTBF (on time performance and service)
  • Increase reliability
  • Improve service delivery
  • Identify fail modes and increase revenue
• Maintenance of Wheelchair Restraints
  • Reduce Injuries
  • Increase customer confidence
  • Ensure ADA compliance

Ms. Berry concluded her presentation by noting that Six Sigma provides a unique approach to resolving real-word problems by combining proven elements of total quality management with systems analysis. This program also promotes professional development of quality and safety staff, and generates cost savings that are readily apparent to executive leadership.

12.  EFFECTIVE PRACTICES IN ACCIDENT INVESTIGATION

The final session of the 11th Annual SSO Program Meeting was devoted to accident investigation. This session included three presentations on accident investigation practices, followed by a question-and-answer period.

Accident Investigation as a Collaborative Effort

Mr. Jerry Shook, State Safety Oversight Program Manager, New York Public Transportation Safety Board, delivered the first presentation of the day pertaining to effective practices in accident investigation. He began his presentation by providing a brief overview of his agency.

The Public Transportation Safety Board (PTSB) was created by the State of New York in 1984, in response to recommendations from the National Transportation Safety Board (NTSB). PTSB was one of the first dedicated safety oversight agencies in the country, and, along with the California Public Utilities Commission, the Massachusetts Department of Public Utilities, and the Pennsylvania Department of Transportation, was one of the models cited by NTSB in its recommendations to FTA to create the SSO program.

When FTA's SSO rule was originally published, Mr. Shook noted that the PTSB was the obvious choice to implement Part 659 provisions for the two rail transit systems in the State of New York: New York City Transit (NYCT) and the Niagara Frontier Transportation Authority (NFTA), a light rail system in Buffalo.

In 1997, PTSB had 12 years of experience, an existing Safety Program Standard, an accident investigation process, a process for managing corrective action plans, and a positive working relationship with the rail transit agencies. Additionally, PTSB had already required each rail transit agency in its jurisdiction to create and implement a System Safety Program Plan.

Mr. Shook noted that PTSB is responsible for investigating or causing to be investigated, all rail transit accidents meeting the reporting thresholds established by Part 659. The investigation process is focused on determining how the accident took place and what caused it. The effectiveness of the investigation process is maximized through a strong working relationship and cooperation with the rail transit agencies, their Safety Offices, and through shared resources.

Mr. Shook explained that resources are an issue for all SSO agencies and for the transit agencies as well. By combining efforts during accident investigation, through participation in rail transit agency accident investigation teams, committees, boards, and task forces, both the SSO agency and the rail transit agency can benefit.

Mr. Shook noted that PTSB has a formal and public process in place for adopting accident investigation reports. Mr. Shook explained that, for each accident investigation, based on the evidence collected and, often in partnership with the rail transit agency, PTSB drafts a report meeting its internal guidelines and format. This report is shared with the rail transit agency.

Meetings are then held to address any concerns that either agency may have. Once these concerns are addressed, the report is sent to the PTSB Board for review and approval. Once approved, it is returned to the rail transit agency for corrective action plan development. Corrective action plans are reviewed and approved by the Board and tracked through fruition, pending any further developments that may arise.

Mr. Shook concluded his presentation by noting that, while specific authorities to request or subpoena records and to formally and publicly approve accident investigation reports can be useful to SSO agencies in conducting accident investigations, it is far more important to establish a positive working relationship with the rail transit agencies. Partnering on critical safety issues, such as accident investigation, enhances the programs and capabilities of both agencies.

Multi-Modal Accident Investigation

Following Mr. Shook's presentation, Mr. Ron Keele presented the Maryland Transit Administration's (MTA) processes for multi-modal accident investigation. Mr. Keele gave this presentation on behalf of Ms. Bernadette Bridges, Deputy Executive Director, Office of Safety and Risk Management, MTA, who had to leave the meeting unexpectedly.

Mr. Keele explained that MTA operates light rail, heavy rail, commuter rail, bus, and contracted commuter bus and paratransit service. Mr. Keele noted that it is the policy of the MTA to ensure that all accidents/incidents, regardless of origin, the operator(s) involved, or of the responsible party, be subject to a formal and objective investigation. Therefore, internal accident notification and reporting requirements are very important.

Mr. Keele noted that all accidents involving MTA vehicles, stations, right-of-way, or other MTA properties under the direction of the MTA Operations Control Center (OCC) are reported to the Office of Safety and Risk Management. Notification is made through MTA's Emergency Notification System (ENS), which alerts all essential MTA personnel, including the Rail Safety Oversight Agency (RSOA), of the accident.

The notifications are received via cell phone, are voice recorded, and automatically assigned a unique identification number that is provided at the end of the notification message. The call is electronically recorded and logged for a period of two weeks.

Once notified that an accident/incident has occurred, it is the responsibility of the Executive Director, Office of Safety and Risk Management, or a designated representative, to provide continuing updates to the app opriate MTA Deputy Administrator(s), regulatory agencies, and other personnel. If necessary, the Director, Office Safety and Risk Management, or a designated representative immediately notifies the National Response Center/NTSB of the accident/incident.

Mr. Keele explained that each MTA mode has been assigned a safety officer who is responsible for responding to the accident. For MARC Commuter Rail, the safety officer is also responsible for coordinating with the FRA . Upon notification and based on the severity of the accident (all fatalities, occupational injuries, high-visibility events, and near misses) modal safety officers respond to the accident scene to perform the accident investigation, according to MTA's accident investigation procedures. The MTA Transit Police also play a critical role in accident investigation. Mr. Keele noted that his RSOA , represented by Mr. Matt Bassett, also frequently responds to rail accidents.

All vehicle operators and MTA personnel are required to follow the appropriate standard and emergency operating procedures (SOPs/EOPs) while at the scene of an accident/incident. The role of on-scene coordinator will often change during the course of the accident/incident. As the first MTA representative at the scene, the vehicle operator serves as the acting on-scene coordinator until emergency responders arrive or until otherwise instructed by the OCC . The primary responsibility of the operator is the safety of his/her passengers and any injured parties. At no time shall the operator volunteer any information regarding the accident/incident to anyone except MTA personnel or the police. It is the responsibility of the operator to assist emergency response personnel as they arrive at the scene and to maintain contact with the appropriate OCC .

As emergency responders and MTA personnel arrive, various mechanisms may be used to control the scene and to begin the accident/incident investigation process. Depending on the severity and location of the accident/incident, access to the scene may be restricted, photographs and measurements may be taken, and witness statements may be gathered. It is the responsibility of all MTS personnel at the accident/incident scene to support all investigation efforts as deemed necessary by the on-scene coordinator. This may include submitting to drug and alcohol screening.

After completing the preliminary investigation, a fact report is generated and provided, within 24 hours, to MTA executive management staff and the RSOA . The Report provides a description of the accident and photographs depicting the physical evidence of the accident scene.

Each report is assigned a unique document control number such as LR.A.09172007-1. This number provides the following information:

• LR = Light Rail
• A = Accident (if this was considered an incident, the A would be replace with an I)
• 09172007 = Month, Day, and Year
• 1= The first Light Rail accident of the day (should another Light Rail accident occur, this number would be 2)

For contracted operations, such as contracted commuter bus and paratransit operations, the contractors' dispatcher is notified of the accident/incident and is then responsible for coordinating and monitoring emergency response efforts. Contractors maintain accurate accident/incident and injury data, and shall cooperate with all accident/incident investigations. This includes submitting comprehensive accident/incident reports to the MTA as well as any other information the MTA deems necessary to conduct an accident/incident investigation and to ensure similar events do not occur.

For MARC operations, all accidents/incidents are reported to the dispatcher for the territory in which the train is operating. The train dispatcher then notifies emergency personnel and coordinates and monitors all corrective and emergency response action required at the site. The Amtrak/CSX Safety Department conducts a formal investigation into the accident/incident and prepares a report or submission to the appropriate authorities. Notification of an accident/incident can be made by telephone, two-way radio, fax or personal pager. The MTA MARC Control Center is also informed of the event and notifies the Office of Safety and Risk Management. By agreement, Amtrak/CSX is responsible for preparing all accident/incident reports for MARC service. The MTA is the reporting railroad however and must authorize all MARC reports prepared by Amtrak/CSX. The MTA is also notified of all accidents/incidents involving CSXT freight operations that may affect MTA operations or services.

For more serious accidents, under authority conferred to the MTA Executive Standing Safety and Security Committee (ESSSC), an Accident/Investigation Board may be established. The Executive Director, Office of Safety and Risk Management is responsible for notifying the AIB members of their participation in the investigation. The safety representative, or ranking safety office staff member, if more than one safety representative is present, serves as the Accident Investigation Board Leader unless the Executive Director, Office of Safety and Risk Management appoints a different leader at the discretion of the ESSSC .

The AIB is authorized to conduct the investigation of the accident/incident in the most expedient manner as determined by the Leader in conjunction with the ESSSC and the Executive Director, Office of Safety and Risk Management. The AIB is also authorized to impound, receive, and examine any evidence related to the accident/incident. The AIB is responsible for maintaining the integrity of the evidence and the chains of custody. In fulfilling this responsibility, secure facilities and assistance from the MTA Police may be utilized. At no time shall the investigation interfere with rescue operations.

In all cases, the MTA strives to identify the causes and contributing factors to the accident/incident and to take immediate corrective actions to ensure that the same or similar type of accident/incident does not occur. Accordingly, it is critical that the accident/incident investigation process maintains a strong link to the hazard and risk identification and resolution process.

Depending on the complexity of the accident, a comprehensive report is required to complete the investigation. This report must be completed and submitted within 30 days to MTA executive management and the RSOA agency, the Maryland Department of Transportation (MDOT). This report may include descriptions of the following:

• Physical Characteristics of the Scene. Physical characteristics include, but may not be limited to a description of vehicle measurements, vehicle condition, posted speed limits, damage to other vehicles or properties, extent of injuries/fatalities to personnel, passengers, or pedestrians, and/or location of landmarks. Photographs of the scene may also be taken depending upon the severity of the accident/incident.
• Interview Findings. Interviews may be conducted with MTA personnel, passengers, witnesses, emergency responders, etc., depending on the extent of the accident/incident. Typical questions asked during an interview may include asking for a description of what was witnessed, the sequence of events, what may have contributed to the accident/incident, or where the individual was located during the time of the accident/incident. Interview findings may also include information gathered from the Medical Examiners Office.
• Sequence of Events. The sequence of events will define the time and date of the accident/incident, when emergency responders arrived to the scene, when applicable Federal, State, and local agencies were notified, when vehicles, equipment, or victims were removed from the scene and where they were taken, and/or at what time the accident/incident scene was released and normal revenue operations began.
• Probable Cause(s) and Contributing Factors. The probable cause will describe the most likely cause of the accident/incident as well as the contributing factors to the accident/incident such as weather conditions at the time of accident/incident.
• Conclusions. The conclusion should be a brief summary of the preceding information with a final classification of the accident/incident as being the result of operator error, pedestrian error, driver error, etc.
• Recommendations and Corrective Actions. Based on the investigation findings, recommendations and corrective actions should be developed and assigned to the most applicable and responsible party for implementation. If necessary, a formal corrective action plan may be developed.
• Document Control Number. A document control number must be assigned to all accident/incident investigation reports so that corrective actions that are developed as a result of the accident/incident can be tracked through fruition.

The MTA works and meets with its RSOA at quarterly review meetings in which accident/incident reports are reviewed for completeness; the status of outstanding findings and corrective actions are reviewed; and report discrepancies and any other additional recommendations by the RSOA are discussed.

Additionally, the MTA ESSSC meets to ensure that all major accident recommendations are implemented as defined by the System Safety Program Plan. The ESSSC also assure that findings and recommendations which cannot be resolved at staff level are presented for executive committee resolution and implementation.

Accident Investigation for Streetcar Systems

The final presentation of the 11th Annual SSO Meeting was provided by Mr. Joe Diaz, System Safety and Security Officer, Hillsborough Area Regional Transit Authority (HART). Mr. Diaz began by describing the TECO Line Streetcar System, operated by HART and located in Tampa, Florida. Phase I of this system opened in 2002, and provides 2.3 miles of service connecting downtown Tampa, Channelside and Ybor City. Phase II, currently in the planning stages, will extend service an additional 1/3 mile into the downtown central business district. It will connect the more than 35,000 people who work in the downtown area to almost every major downtown parking structure.

Mr. Diaz noted that, while small, the TECO streetcar carries passengers to and from numerous businesses, major hotels and entertainment venues throughout the Ybor and Channelside districts. The line also provides service to the Tampa Convention Center, Tampa Aquarium, Port of Tampa Cruise Ships, and the St. Pete Times Forum - home of the Tampa Bay Lightning.

Mr. Diaz noted that average annual ridership for the streetcar is 419,878, with an average monthly ridership of approximately 34,989. Over sixty percent of TECO streetcar service is provided to tourists and over 60 percent of TECO's ridership occurs on the weekends. Mr. Diaz also noted that current ridership statistics show an increase of approximately 40,000 riders for Fiscal Year 07. Several key special events have generated this increased ridership. TECO streetcars can also be chartered for special occasions such as conventions, weddings, parties.

TECO operates a conventional electric rail (600V DC) overhead catenary system (OCS). It is a single-track, bi-directional system with six sidings (passing tracks) to permit the passing of streetcars traveling in opposite directions. Streetcars operate by line of sight with one direction having right over the other. Streetcars traveling in the opposite direction must enter designated sidings and await the arrival of the streetcar traveling in the opposite direction.

Mr. Diaz explained that HART owns ten historic replica streetcars: nine Birney cars and one breezer-style car all purchased from the Gomaco Trolley Company in Ida Grove, Iowa. In addition to the ten Gomaco cars, a restored standard single truck Birney Safety Car owned by the Tampa and Ybor City Street Railway Society is also housed at the Ybor Station facility.

A key feature of the system is an at-grade crossing (Ybor Interlocking) of the CSX Railroad's Tampa Terminal Subdivision located near the old alignment of 13th Street between 4th and 5th Avenues in Ybor City. CSX personnel conduct training on interlocking to student motormen.

Mr. Diaz noted that the streetcar tracks do not share vehicle travel lanes, and are separated from street traffic by low barriers and landscaping. At signalized intersections, a separate signal (Opticom) is linked to the traffic control system. Mr. Diaz pointed out that one would think that the possibility of accidents would be limited to driveways and intersections.

However, this is not the case. Mr. Diaz then proceeded to show a number of photographs depicting automobiles (including a police car) that had crossed the barriers and landscaping into the streetcar tracks and struck a TECO streetcar. He noted that since 2003, the TECO system has experienced 69 total incidents to date and that 43 of these incidents involved automobile turns/pulls in front of streetcar. Mr. Diaz observed that, statistically speaking, an automobile turning/pulling in front of the streetcar is the biggest threat to system safety.

Mr. Diaz joked that HART has had so much experience investigating streetcar accidents, that the agency has been forced to revise its accident investigation procedure a number of times. The most current version is called "Investigation of Incidents and Hazardous Conditions Procedure, No. 2, Version 8, January 2007."

Mr. Diaz then reviewed the procedure and showed the forms used to document the investigation. Mr. Diaz noted that the procedure explains how investigations will be conducted by the HART Office of Safety and Security for Streetcar Operations. The procedure also applies to any identified hazardous condition. A second purpose of the procedure is to provide a uniform policy for the establishment and assembly of a HART Incident Investigation Team.

Mr. Diaz noted that "major incidents," including a fatality or multiple injuries, a collision, derailment or fire that causes property damage in excess of $25,000, or a hazardous condition, are investigated by the HART Incident Investigation Team, as directed by the HART Office of Safety and Security. "Minor incidents," which includes everything else, are investigated by frontline supervisory personnel, as directed by the Office of Safety and Security.

When investigating a "major accident," the HART System Safety and Security Officer is the Team Leader. Permanent members of the HART Incident Investigation Team are designated by the Office of Safety and Security and include the following: System Safety and Security Officer, Manager of Streetcar Services, Risk Management, and a Transit Supervisor. A minimum of three (3) team members are used for investigation when activated.

During investigations, the HART Incident Investigation Team is responsible for performing the following activities:

• Identify, collect, assemble and preserve all equipment, documents, facts and information relevant to incidents involving HART property or any persons involved in such incidents.
• Determine the cause(s) of the incident, together with contributing factor(s) and/or conditions.
• Identify corrective actions required to help prevent future similar incidents.
• Provide written reports (interim, preliminary and final) identifying probable cause(s) of the incident and remedial actions required.

The Initial Incident Reports include:

• HART Primary Person Conducting the Investigation (Name, Title)
• Event Type (collision, derailment, fire, explosion, security, other)
• Location, Time, Date, Direction of Travel
• Fatalities, Injuries
• HART Vehicle(s) Involved (Type, Number)
• Other Vehicle(s) Involved (Type, Number)
• Property Damage Estimate
• FDOT Reportable
• Description of the Event/Narrative/Synopsis
• Photos
• Diagrams
• Witness Statements
• Post Accident Drug and Alcohol
• Police Report Number

Mr. Diaz noted that HART spent a lot of time working on its accident investigation form, including the creation of diagrams with images of the streetcar, to ensure that both HART personnel and Tampa police could accurately document the accident.

Mr. Diaz also explained that, for minor incidents, all Motorman Accident Reports are submitted to Dispatch for time and date stamp on the same day of event. All Transit Supervisor Accident Investigation Report/Materials are placed in a manila envelope with checklist label to identify all items contained in envelope:

___ Supervisor Narrative

___ Supervisor Diagram

___ Police Report Number

___ Accident/Incident Notification

___ Photos (memory card)

___ Courtesy Cards

Mr. Diaz explained that HART 's Risk Department personnel pick up all reports twice daily Monday through Friday. The Risk Department provides Safety Department with copies of all reports daily, and the Safety Department reviews all reports and records them categorically in a Monthly Occurrence Incident Summary Log.

Mr. Diaz also explained how HART reviews the accident reports with employees. First, accidents/incidents involving any HART vehicle are reviewed by the Safety Officer to determine preventability. Prior to the rating, the Safety Officer meets with the employee to discuss the accident/incident. At the meeting, the employee is informed of the rating. The employee receives written notification of rating and if preventable, penalty. The employee is entitled to appeal the preventable rating to the Tampa Area Safety Council.

Mr. Diaz then explained the discipline for involvement in a preventable accident within a 12-month period:

• First Offense -- Retraining
• Second Offense -- Reprimand - mandatory attendance in defensive driving course
• Third Offense -- One day suspension
• Fourth Offense -- Three day suspension
• Fifth Offense -- May Discharge

Mr. Diaz also explained that individual accidents drop from an employee's record after 12 months from date of accident. Mr. Diaz noted that as a result of this policy, a number of streetcar motormen were forced to resign.

Mr. Diaz ended his presentation by reviewing several hazardous conditions that the system has experienced since it began operation and how they have been resolved. On the street running sections of the alignment, trolley operators found it difficult to judge the distance to intersections and motorists sometimes found it difficult to judge the distance between their vehicles and the trolley/right-of-way. As a result, side impact collisions did occur. To resolve this hazard, Mr. Diaz and his staff worked with the city of Hillsborough to paint lines on roadway pavement to clearly delineate the operating envelop of the trolley.

Mr. Diaz also described that, in response to a series of yard derailments, a program was developed for re-training motormen and providing written safety warnings. Right yellow clearance Lines were also painted in the Barn and Yard.

Mr. Diaz explained that, as a result of one collision in 2004, an automobile hit and damaged a switch box. HART repaired the switch, put in a speed restriction, and acquired an outside contractor to inspect switch and provide written documentation of switch condition.

Mr. Diaz provided another example in which the HART determined that it was unprepared to remove trolleys from service and to store them in a safe location during an extreme weather event such as a hurricane. In response, the organization entered into an agreement with a local towing contractor and executed a mock exercise to determine how long it would take to remove a trolley from service and place it into storage. HART personnel determined that approximately three hours are required to remove one trolley from service, transport it to the contractor's storage site, and return to get the next trolley. The agency has since developed a plan for emergencies such as these.

Mr. Diaz noted that he has established a strong relationship with his SSO agency, the Florida Department of Transportation (FDOT). He pointed out that FDOT and the SSO Program Manager, Mr. Mike Johnson, support his activities, provide a thorough review of his accident investigation reports, and actively track the status of his corrective actions. Mr. Diaz noted that FDOT oversight has been particularly helpful to use a leverage point in working with the city of Hillsborough on getting corrective actions implemented, such as the painting of lines on roadways.

Mr. Diaz concluded his presentation by observing that even though the job of keeping a rail transit system safe may sometimes feel like a gigantic, overwhelming task, it is critical, in the words of Winston Churchill, to "never, never, never give up."

Questions and Answers

After the presentations, participants asked Mr. Shook, Mr. Keele, and Mr. Diaz questions about the types of accidents they investigate, the biggest challenges they face in addressing Part 659 accident investigation requirements, and how they communicate with transit supervisors and police during accident investigations. Mr. Diaz also received several technical questions regarding the operation of the TECO streetcar.

CONCLUSION

The 11th Annual SSO Program Meeting concluded with an open forum for discussion. Participants identified what they liked about the meeting and areas for improvement. See Appendix C of this report for greater detail.

Several locations were suggested for the 12th Annual SSO Program Meeting, including San Juan, Puerto Rico and Charlotte, North Carolina. FTA will coordinate with SSO and rail transit agency officials prior to making a final determination on the site of the next workshop.

Mr. Taborn officially adjourned the 11th Annual SSO Meeting, and thanked all participants for their hard work, contributions, and commitment to safety and security.

Appendix A: Meeting Participants

11th Annual

State Safety Oversight

Program Meeting

September 2007

Meeting Participants