The National Transportation Safety Board (NTSB) has released the final report from its investigation of the October 2021 Metro derailment, and NTSB Chair Jennifer Homendy criticized the Washington Metropolitan Area Transit Authority (WMATA) for not taking quicker action to correct a known problem that caused a train car to slip off the tracks.
The derailment happened because a set of wheels on a 7000-series train car had gradually migrated outward on their axle, leaving the wheels two inches farther apart than specifications required, the NTSB found. The eight-car train derailed and rerailed itself twice earlier in the day on Oct. 12, 2021, before coming to a complete stop between the Rosslyn and Arlington Cemetery stations in Northern Virginia while 187 people were aboard.
No one was seriously hurt, and all cars remained upright, but the derailment forced frightened passengers to evacuate the system through a dark tunnel and spurred the transit agency to pull its 7000-series railcars out of service. Those cars are Metro's newest, making up more than half of its fleet.
We're making it easier for you to find stories that matter with our new newsletter — The 4Front. Sign up here and get news that is important for you to your inbox.
“We’re lucky, absolutely lucky, that this didn’t end up in a tragedy,” Homendy said.
She went on to blast a "poor safety culture" at Metro, citing decades of problems and previous fatal incidents. She also said that she would still ride Metro, and commended the agency's new General Manager and CEO Randy Clarke for taking this derailment seriously. Clarke joined Metro in 2022.
The derailment brought to light problems with the 7000-series railcar wheels that continue to impact service: Dozens of wheelsets on Metro cars have moved after manufacture, a process called wheel migration, Homendy said. This migration meant the wheels were spaced too widely apart for the tracks.
Metro says it currently inspects 7000-series cars every 30 to 60 days.
Metro is currently in the midst of a years-long effort to redo hundreds of the wheelsets in question and says the railcar manufacturer, Kawasaki, is responsible for footing the massive bill. Kawasaki said it met Metro's design specifications.
Metro said it fully supports the NTSB report and thanked the NTSB and Washington Metrorail Safety Commission (WMSC) for helping to move the process forward.
Metro saw problems with wheelsets migrating in the years before the crash. There were four in 2017; one in 2018; four in 2019 and four in 2020, the NTSB said Thursday.
"We found that one department within WMATA was aware of wheel migration in its railcar fleet and attempted to mitigate the associated safety risks, but the department did not conduct a trend analysis to monitor the incidence of wheel migration or how effective its mitigations were," the NTSB report summary said.
Then, the number skyrocketed. Eighteen wheelset migration issues were reported in 2021 before the derailment in October.
Train derailed and rerailed twice before coming off tracks between Rosslyn and Arlington Cemetery stations, the NTSB said
NTSB investigators found evidence that train 407 derailed two other times in the roughly 90 minutes before the crash but was pushed back onto the tracks and continued service.
At 3:24 p.m., the train was traveling north and derailed near Arlington Cemetery. Surveillance video shows the fifth railcar popping upward as its rear wheels come off the tracks, according to the NTSB.
At 4:13 p.m., the same car derailed near Largo Town Center while traveling west. Video shows dust flying into the air, which is consistent with a derailed wheel disturbing concrete, the NTSB said.
In both cases, the train car came back onto the rails as it passed over a “frog area” that’s designed to allow trains to switch from one set of tracks to another.
“The wheels leading from track two to track one pushed the wheelset back into position,” a video shown by the NTSB said.
Finally, the eight-car train derailed at 4:49 p.m. at the switch about 166 feet south of the Rosslyn station, where the Blue Line separates from tracks for the Silver and Orange lines.
“Because there was no crossover leading back to the Blue Line to guide the derailed wheelset back onto the track, the train remained derailed,” the video said.
Passengers were evacuated through the Arlington Cemetery station.
Investigators found that the wheels were two inches farther apart than allowed by design specifications.
'Poor safety culture'
NTSB Chair Jennifer Homendy skewered Metro's "poor safety culture" and its "failure" to evaluate and mitigate safety risks during Thursday's news conference, saying that recommendations and warnings issued to Metro years and even decades ago could still be applied today.
"It's this same story again and again, since 1970," when the system was still under construction, she said. "In case after case, WMATA struggles to proactively identify safety hazards, including low-probability, high-consequence risk. When they do identify hazards, they're not communicated within the organization. Mitigations are put in place, but then those mitigations are not monitored or measured for effectiveness. And the hazards themselves aren't tracked to see if there's a trend over time, and to see if more actions need to be taken."
"This accident is no exception," she said.
Homendy said WMATA knew about the wheel migration issue since at least 2014, which means the problem predated the 7000-series railcars. The transit agency contracted a study in 2015 and began receiving 7000-series cars while it was still underway, she said. WMATA identified the same issue in the 7000 series in March 2017; three months later, it changed the specification to increase mounting forces on wheelsets.
But by then, WMATA had already received almost 500 railcars in the 7000-series, or about 66% of all cars in the series, Homendy said.
Wheelsets are made by pushing wheels onto the axle with an enormous amount of pressure. The axle is bigger than the wheel’s center hole, and the joints are held together by friction. Wheelsets assembled with more force are more resistant to wheel migration, the NTSB found.
The original specifications required 55 to 80 tons of force; that increased to 65 to 95 in 2017.
"Instead of replacing the wheelsets to the new specs, as they're doing today, they chose to leave 66% of the 7000-series railcars with the old spec in service, including this rail car [that derailed], and put the rest of the 7000-series under a new spec," she said.
Even under that updated specification, she said, Metro continued to see wheel migration. Despite this, those railcars remained in service.
In the four years before the 2021 derailment, Homendy said, WMATA found migration issues in about 30 wheelsets. After pulling 7000-series cars from the tracks, WMATA inspected all 2,992 of their wheelsets and found another 50 that exceeded the maximum allowable distance between wheels. However, none of those wheelsets had moved as much as the ones that caused the derailment, the NTSB said.
Now, WMATA is repressing all wheels with 80 to 120 tons of pressure.
But if WMATA had done a risk analysis, the derailment may have been avoided, Homendy said.
"As with any NTSB investigation, the key isn't determining what happened, which we know pretty early on. But it's how it happened. That's how we prevent future accidents and tragedies," Homendy said. "But once we issue those safety recommendations, those recommendations need to be acted upon. Otherwise, safety isn't assured."
Homendy made no effort to hide her concerns with Metro.
"Human error is a symptom of a system that needs to be redesigned. And when it comes to WMATA, they need to be proactive, not reactive, to assure safety," she said. "We're lucky, absolutely lucky, that this didn't end up in a tragedy, in a derailment where there were potentially deaths or serious injuries."
Homendy also shared an excerpt from the NTSB's report on its investigation into the deadliest crash in Metro's history, a 2009 collision near the Fort Totten Metro station that killed nine people and injured dozens more.
"This line, from 2009, applies to today, years later: 'Shortcomings in WMATA's internal communications, in its recognition of hazards, its assessment of risk from those hazards, and its implementation of corrective actions are all evidence of an ineffective safety culture within the organization.' Again, that was from 2009," she said. "You could take that line and apply it to today."
What's next?
Safety inspections and work to ensure the newer railcars are safe continue to affect Metro service more than two years later.
Ahead of Thursday’s briefing, NBC Washington learned that Metro has issued a “fleet defect letter” to Kawasaki, the manufacturer of the 7000 series railcars, essentially saying the company is responsible for fixing the cars.
Metro wants Kawasaki to pay for all costs to fix wheelsets on hundreds of 7000-series railcars. Repressing the wheels on 748 train cars is estimated to cost $55 million.
Kawasaki said they pressed the wheels based on Metro's specifications and claims Metro failed to notify the manufacturer of changes to the wheel specifications that were made before the first 7000-series cars were delivered.
"As expected, the NTSB’s conclusions align with our own findings and confirm that Kawasaki met the design and mounting specifications established by WMATA for the 7000 series wheelsets. While we understand the budget crisis that WMATA is facing, any suggestion that Kawasaki should absorb the cost of WMATA’s own failures regarding the wheelsets of the 7000 series trains is not rooted in reality," the company said.
“Any suggestion that Kawasaki should absorb the cost of WMATA's own failures regarding the wheelsets of the 7000 series trains is not rooted in reality,” the company said.
That sets up a likely legal battle over the cost to fix the 7000-series railcars.
Nearly a year ago, the NTSB revealed new details on the derailment and released an image in which one Metro railcar appears higher than the others on the train that derailed. The NTSB describes that as “vertical car body disturbance.” In another picture, the same train is seen running its wheels on the ground and kicking up dust.
A lot of attention has been paid to the amount of force used to press wheels together on the 7000-series train cars. The wheels on the 7000-series had been moving outward.
Work underway to fix wheels on hundreds of Metro's 7000-series train cars
Metro announced last month that it's begun replacing wheels on all 7000-series cars. It's a time-consuming process, requiring 72 hours of work on each pair of cars, followed by 30 hours of inspections, according to a press release.
“It will take an extensive amount of work over the next few years, but as we begin to have more 7Ks available, customers will begin to see even more improvements in reliability and service," Metro chief Clarke said.
Metro developed a plan to press wheels on the 7000-series cars at a higher standard after analyzing an NTSB technical report, the release said.
That report cited “engineering experts who identified a technical issue – microslip due to reduction in contact pressure – as a factor in the 7K wheel migration issue,” the release said.
The number of 7000-series trains on Metro's tracks is limited while the repressing work moves forward. Meanwhile, Metro continues to use its "oldest, least reliable railcars" to get passengers around.
Sign up for our Breaking newsletter to get the most urgent news stories in your inbox.
Safety concerns and slowdowns hindered Metro’s efforts to entice passengers back after the pandemic. Transit riders were waiting upwards of 20 minutes and sometimes up to 40 minutes for train service.
Metrorail ridership on weekdays is 55% of its pre-pandemic levels, according to Metro's latest report. Bus ridership and weekend ridership have rebounded more.
