Two technicians who were struck by a hi-rail vehicle died because of inadequate safeguards provided by their employer, the Washington Metropolitan Area Transit Authority (WMATA).

That investigation conclusion by the National Transportation Safety Board (NTSB) was double edged: the NTSB also found that hi-rail operators were not informed that the technicians would be at that location.

The technicians were struck and fatally injured while repairing the signal system on a section of track near the Rockville, Maryland station on January 26, 2010,

The NTSB determined that the probable case was WMATA’s inadequate safeguards designed to protect roadway workers from approaching hi-rail vehicles, and their failure to ensure hi-rail operators were aware of any roadside work being performed.

“Any transit agency must ensure the safety of its employees as-well-as its passengers,” said NTSB Chairman Deborah A.P. Hersman. “That is why the NTSB included safety management systems on its Most Wanted List. These reports underscore the need for an effective safety management system: it must be the central part of an organization’s operating plan and it must be understood and embraced by all employees, at all times.”

On the night of the accident, several on-track maintenance vehicles were scheduled to be moved through the area in which the automatic train control technicians were working. Contributing to the accident was the inadequate communication of vital information concerning the ongoing work on the tacks by the Operations Control Center to the on-track maintenance vehicle. The crew of the hi-rail vehicle was not advised of the presence of other workers in the area. In addition, the hi-rail vehicle operator and crew as-well-as the two automatic train control technicians all failed to appropriately and effectively observe activity on the tracks.

Since the accident, WMATA has taken several actions to address roadway worker safety. These include improvements to procedures to provide better protection to all roadway workers, the issuance of a new Roadway Workers Protection Manual, and upgrades to all hi-rail vehicles.

As a result of their proactive efforts to address the safety issues identified in this investigation, the NTSB did not make any recommendations to WMATA. However, safety recommendations have been made to the Federal Transit Administration (FTA), the agency responsible for ensuring state safety oversight of rail transit agencies, and to the American Public Transportation Association, which issues the Standard for Work Zone Safety.

Included in the four safety recommendations to the FTA is a recommendation to notify all rail transit agencies and state safety oversight agencies of the circumstances of the 2010 accident at the Rockville, Maryland station and urge them to evaluate their roadway worker protection programs. The purpose - to ensure other agencies are adequately and effectively addressing appropriate training, communication, maintenance-vehicle movement authority, flagging procedures, rules compliance, and the sharing of work areas by multiple work crews.

In addition to the Rockville Station accident, the NTSB released final reports on two other WMATA accidents.

• Farragut North station: On February 12, 2010, the front wheel set of Red Line train 156, with 345 passengers aboard, derailed as the operator attempted to enter the main track at the Farragut North station in Washington, DC. The train operator’s failure to follow proper operating procedures, which resulted in the train operating past a red signal and over the interconnected derail, was determined to be the probable cause of the accident.

• West Falls Church Yard: On November 28, 2009, at approximately 4:30 a.m. in the West Falls Church rail yard in Virginia, train 902 struck the rear of a standing train. Two WMATA maintenance car cleaners onboard the struck train and the operator of train 902 sustained minor injuries. The NTSB determined the probable cause of the accident was the failure of the train operator to control the movement of the train as it approached the standing train, possibly due to fatigue.

A synopsis of all three reports, including the probable causes, findings, and a complete list of the safety recommendations, are available on the NTSB website. The full reports will be available on the website in several weeks.

On May 29, 2012, a WMATA worker was involved in an accident at the Shady Grove Maryland rail yard. While the NTSB is aware of the accident, this accident is being investigated by WMATA.