SRA 231 NTSB-2 METRO MISHAP

REPORT

Stephen Giacobe, Adam Gilbert, Evan Leckenby, Sam Gross,

Olivia Weiss
 TASK FORCE MISSION

• National Transportation Safety Board

• Investigation of significant accidents that occur within all modes of
transportation
• Preventing potential future incidents
• Strong focus on the “how”
• Will not sacrifice this control to competing agencies until our mission
as been completed
 ANALYTIC FOCUS

• Determine the causality of the incident

• Not concerned with the motive or the intent of the incident
• Specific focus:
• Human factors
• Environmental factors
• Operations
• Maintenance and Design
 BLUF

A heat activated substance was placed on Relay Point 5 of the Automated Signals Processing
Unit (ASP) in Blue Line Train-17. The interference from the substance in the ASP rendered
signals coming from MTA Central Control useless, completely separating the connection to the
Throttle Control Assembly (TCA). Without a proper connection to the TCA, MTA Central
Control was unable to stop Train-17, which proceeded to crash into Orange Line Train-6 at the
Farragut West Metro Station. The accident resulted in several deaths and a vast array of injuries.
The remainder of our presentation will establish the basis for our findings and demonstrate
how our analysis and supporting evidence led to our analytic judgments.
 SCENE SETTING

• 1 April 2011 at 10:55:25 Blue Train Line-17 collided with Orange Train Line-6
• The Orange Train Line was getting ready to depart from Farragut West Metro
Station
• Several deaths and an even greater number of injuries occurred as a result
• Investigation to determine the “proximate cause” or the “how” of the mishap
• Breakdown of all factors impacting the Blue Train Line
• Searching for the nail in the horseshoe
CRASH TIMELINE
 MISHAP BREAKDOWN

• Heat activated substance placed on Relay Point 5 of the Automated Signals Processing Unit (the
nail)
• ASP loses connection to the MTA Central Control operation
• Separates connection to the Throttle Control Assembly which has the ability to remotely slow the
train down
• Known to be true because the Throttle Control Assembly was tested on another engine running the same
set of track and worked perfectly
• The mishap conductor died before the incident but would not have been able to stop the crash if
he had lived
• The blunt force trauma suffered after the incident was also sufficient to cause death
• Foreign substance was introduced manually, suspect would need to have a full working knowledge
of the system
• A knowledge well beyond an MTA maintenance employee
Not geographically accurate representation
of where the control center, metro station,
and crash site are in relation to each other
EVENT TO PERSON MATRIX

Human factors plays a major role in the Metro Mishap

MISHAP CONDUCTOR ANALYSIS
 CONCLUSION BLUF RE-STATEMENT

A heat activated substance was placed on Relay Point 5 of the Automated Signals Processing
Unit (ASP) in Blue Line Train-17. The interference from the substance in the ASP rendered
signals coming from MTA Central Control useless, completely separating the connection to
the Throttle Control Assembly (TCA). Without a proper connection to the TCA, MTA
Central Control was unable to stop Train-17, which proceeded to crash into Orange Line
Train-6 at the Farragut West Metro Station. The accident resulted in several deaths and a vast
array of injuries.
 CONCLUSION RECOMMENDATIONS

• Further investigation into potential suspects

• Proper testing of all train system operations
• Specific focus on communication between Automated Signals Processor and
MTA Central Control
• Increased security along the metro
• Including hidden security cameras
 UNFINISHED BUSINESS

• It may be to the benefit of other agencies to investigate these issues further:

1. Japanese Involvement and Interest
2. Blue 17 Running 8 Cars
3. Mishap Conductor Poisoning
4. Cyber Attack on District Computer Network
5. Criminal Investigation Involving Vent 22
6. Spray Painting of Tunnel Cameras
7. Hydrogen Cyanide Backpacks
 ROLES AND CONTRIBUTIONS

Group Member Contribution

Adam Gilbert PowerPoint, BLUF, Briefer
Sam Gross Timeline, Briefer
Evan Leckenby Event to Person Matrix
Olivia Weiss Analysis of Competing Hypothesis
Stephen Giacobe Metro Mishap Illustrations, Mishap
Conductor Research
 THANK YOU

• We wanted to take the opportunity to thank everyone for all the hard work
dedicated to this investigation and wish you luck in any future proceedings.