Report # IS062513 Print Form California Public Utilities Commission Rail Transit Operations Safety Section Incident Summary Form Form #IS 12-28-12 Revision 3 Form R or RSIMMS Number N/A Agency Santa Clara Valley Transportation Authority Contact Michael Brill Address City 3331 North First Street (VTA) San Jose State CA Agency Contact Date Field 2013-06-25 Time Field 08:00:00 Zip Code michael.brill@vta.org Personnel Present Name Title E-mail Rupa Shitole CPUC Utility Engineer rupa.shitole@cpuc.ca.gov Thomas Govea CPUC Signal Inspector thg@cpuc.ca.gov Donald Filippi CPUC Operating Inspector dgf@cpuc.ca.gov Garry Stanislaw VTA System Safety Supervisor Garry.Stanislaw@VTA.Org Michael Brill VTA System Safety michael.brill@vta.org CPUC Representative Rupa Shitole Inspector Donald Filippi (Operating Inspector) Inspection Location Mile Post CPUC or DOT Crossing # Signal # D33, D48 Station or Facility Name Guadalupe Yard, VTA Maintenance Facility CPUC Transit Operations Safety Section Incident Summary Form Page 1 of 4 Switch # Incident Work Sheet Type of Incident Signal/Track Circuit Failure Number of Injuries 0 County San Clara # of Vehicles/Cars 2 Signal System ABS Train Identification 49, 32, and 34 Was Haz-Mat Involved N/A Incident Crew Operator #5698 Crew Member Unknown Incident Response # of Employees Injured 0 Warrants/Bulletins Yes Down Load/Video Yes Emergency Response Contacts Gary Stanislaw - Garry.Stanislaw@VTA. Org Lead Investigator John Carlson Contact Info. Carlson_J@vta.org Rupa Shitole - 415-314-5845 Measurements/Notes First Incident Time - 16:12 Second Incident Time - 17:20 Line - 902 Train - 49, 32, & 34 Vehicle Numbers - 993, the rest unknown at this time. Operator - 5698, other Operators unknown. Operator reported that he/she was unable to receive a proceed indication from the signal at D33(Diridon), southbound. SCADA system indicated a request from signal D48 was entered at Fruitdale northbound without any train presence. SCADA was also indicating that Race was in Local Mode, 712, 718, & 723 (Signal Personnel) responding. Per 723, Race was in remote mode and Signal Personnel were putting the crossing gates at Fruitdale in manual mode. Vasona Line trains were advised. At 16:43, while train 32 was heading northbound in the single track area, train 34 from Diridon (southbound) received a proceed indication from signal D33 and entered into the single track area. OCC stopped train 34 and had the train reverse back into Diridon on the southbound platform. Per 718, the proceed indication that was given at D33 (Diridon), (even though a train presence was detected in the single track area) was due to a bad VHLC NVIO card at the Fruitdale signal house. Signal personnel were replacing the card, Diridon, Race, & Fruitdale were all placed in Central Control and all trains were manually guided through the single track area by OCC. At 17:20, a false presence was detected at Bascom southbound. OCC placed Bascom into Central Control and manually moved trains through this area of single track. At 17:23 the false presence was cleared when train 45 went through the affected track circuit (D49DT). OCC placed Bascom back into Field Mode at 17:29 hours. At 18:17, Per 718, the card had been replaced at Fruitdale and the Vasona Line was functioning normally. Per 329/348 (Controllers). CPUC Transit Operations Safety Section Incident Summary Form Page 2 of 4 Incident Information: Staff performed an incident investigation on June 25, 2013. Staff was given a copy of the Unusual Occurrence Records for 6/19/13 through 6/21/13, staff was also given a copy of the Train Orders for 6/21/13, 6/24/13, and 6/25/13. Staff was provided a copy of the existing SOP that was created after the five similar incidents noted in November of 2012. Staff viewed the OCC recording, this was the actual event as it happened on the SCADA Log, staff was able to see what the Controllers saw on the day of the incident. All of this information has been attached to the Incident Summary. Staff conducted a similar incident investigation on January 08, 2013. Staff found that two trains proceeded onto the single track portion between Fruitdale and Diridon. One train received a proceed indication from the signal, the other train received a stop indication and was later given authority to bypass that signal. Both trains were approaching a head on head collision on single track, the trains were eventually stopped by the Controller prior to a collision. Staff noted that the cause of this failure was due to the VHLC NVIO Card, the card was defective and the current Operating Procedure was ineffective. Staff discovered the same scenario during our investigation on 6/25/13, staff verified at least two additional failures since the 1/8/13 investigation. Even after VTA restructured their SOP in an attempt to deal with these types of situations, it was discovered that there were deficiencies that did not allow for some human errors. Some of the Controllers misinterpreted the content in the SOP and were confused when it came time to implement those procedures. Additionally, staff is very concerned with the fact that these trains were both traveling at a high rate of speed. The train that received a proceed indication was authorized for 55 mph, the train that was given authority to bypass the stop indication was authorized for 45 mph. VTA does not require a train, once they are authorized to bypass a stop signal, to proceed at restricted speed if the situation is considered a "Known Failure". VTA's explanation is that they know about the failure so the train can proceed at 45 mph, the concern is that bypassing a signal puts the operator in a situation were they are not sure what is ahead of them. That was made obvious by the multiple failures experienced in this area resulting in multiple head on head train movements. Any train bypassing a signal should operate at restricted speed, allowing the operator to stop in half the range of vision of what ever may be ahead of that train. In addition to subpar Operational Procedures, VTA is also having to deal with subpar equipment. The current signaling system is ineffective and the equipment is unreliable. VTA informed staff that they would consider rehabbing the current system on the Vasona Line, however this would be a long term fix. Staff is concerned with the short term corrections as well, staff has requested that VTA place a Stop and Call procedure between Fruitdale and Diridon, as well as Bascom and Campbell. VTA placed the Stop and Call order between Fruitdale and Diridon, and has informed staff that they intend on rewriting their SOP to address some deficiencies. Staff believes in the interest of safety, the following items should be implemented immediately at VTA, 1. VTA should implement a Stop and Call procedure at all single track portions of the Vasona Line until the signaling system is corrected. 2. Staff believes that any operator given authorization to bypass a stop indication should not exceed 25 mph, and should be able to stop in half the range of vision of anything ahead of the train movement. 3. VTA should rehab their signaling system on the Vasona Line to ensure that all equipment will be reliable and function as designed. 4. The current SOP should be restructured to include additional precautions that will ensure safe transportation of the public. Note: Please click on the paper clip at the bottom left corner of your screen in order to access the attached documents. CPUC Transit Operations Safety Section Incident Summary Form Page 3 of 4 Item #1 Diridon Interlocking Item #2 False Occupancy at Fruitdale Item #3 OCC Recorded Playback Item #4 Left Blank Item #5 Left Blank Item #6 Left Blank CPUC Transit Operations Safety Section Incident Summary Form Page 4 of 4