NTSB photo

Prior to the June 22, 2009 crash on the Red Line, Metro had experienced two other serious collisions. These incidents both occurred on the Red Line, one in 1996 near Shady Grove, and another in 2004 at the Woodley Park station. The crashes raised several concerns, including questions about the crashworthiness of Metro’s railcars. In both of these collisions, the impacting railcar “telescoped,” causing significant damage. The topic of retiring the Series 1000 railcars has been discussed previously at length. However, other questions were raised in the 1996 and 2004 crashes that are worthy of analysis.

January 6, 1996 was a cold and snowy evening in the Washington, D.C. region. Metrorail train T-111 was traveling on the Red Line in the direction of Shady Grove, operated by Darel W. Callands. At 10:27 PM, Callands alerted Metro’s Operations Control Center (OCC) that his train had overrun the platform at Twinbrook. He was directed to continue on to the Rockville station, where his train overran the platform by one car. Callands was able to service the station, and continued on to the final station stop at Shady Grove. The train, operating in full automatic mode, did not slow as it approached Shady Grove. It passed through the station, slowing to 35 mph only as it passed the north end of the platform. About 500 feet past the platform the train struck a standing out-of-service train. Two passengers on board escaped without injury, but Callands was killed.

The official NTSB report would identify several probable causes for the crash. The immediate cause was decreased braking performance due to weather conditions. The automatic train control system did not account for this loss in braking efficiency and resulted in the train’s inability to slow down properly.

Looking at the bigger picture, the NTSB identified several problems that led to the tragic outcome. Prior to the collision, after experiencing multiple station overruns, Callands should have been advised to operate the train in manual mode. However, Metro had instituted a policy that required full automatic operation at all times. Metro had also abolished the practice of train operators running on manual mode with frequency in order to stay in practice. All of this caused on Metrorail to depend completely on automatic mode under all circumstances. Furthermore, the gap train should not have been located on the same track as an inbound train. Overall, the conclusion was that Metro implemented new policies without understanding the possible safety ramifications, and without providing proper training to control center employees and train operators.

The NTSB issued a series of recommendations dealing with the specific circumstances surrounding this crash. However, the organizational concerns would be harder to address. Ultimately, none of the individual failures that occurred on January should have resulted in a collision. Rather, a lack of coherent procedures and an established atmosphere of safety allowed these failures to compound, resulting in a serious accident. From the NTSB report:

The Safety Board found WMATA management policies and methods to be inconsistent with the needs of a technically complex automated rail system. Systematic analyses of organizational processes reveal that managers operating highly automated systems must successfully contend with unique demands presented by the automation itself. One fundamental requirement for managing automated systems is to contend effectively with “tight coupling” between different operating elements in the system. That is, in organizations operating highly technical automated systems, decisions that affect one activity in the organization will probably affect other activities and will sometimes produce unanticipated hazards.

High-technology organizations must also be capable of both centralized and decentralized control. Operating activities need to be controlled within “tightly prescribed steps and invariant sequences,” thereby ensuring that actions suitable in one circumstance or departmental area do not conflict with other activities in the system. At the same time, operating personnel occasionally have to be able to take “independent and sometimes…creative actions” in order to prevent the development of unsafe conditions. Finally, high-technology organizations must have safeguards to prevent unsafe conditions that may result when the automation compensates temporarily for deficient operation and then fails to protect the system when unforeseen factors combine and breach the system’s safeguards. This condition poses the greatest threat to the safety of a complex system and must be addressed in well conceived system planning.

Given the extent to which WMATA executive management was found to depart from these essential organizational characteristics, it is not surprising that flawed decisions, inadequate or ambiguous train control procedures, and poorly understood or unenforced rules had proliferated.

While Metro may have responded with targeted fixes to the immediate problems, the 1996 accident would not prove to be a catalyst for widespread safety improvements. As noted in the previous installments, time and again similar concerns would be echoed by the NTSB and other observers.

On November 3, 2004 at 12:49 pm, an out-of-service Red Line train rolled backwards into the Woodley Park station, striking an in-service train that was servicing the platform. Twenty people were injured in the incident. The NTSB would identify the cause of the crash as a lack of rollback technology, coupled with a lack of attentiveness on the part of the operator of the out-of-service train. This lack of attentiveness would be attributed to a lack of proper time off between shifts. Had this accident occurred with two fully-loaded trains, the casualty count would have been much greater. Concern persists to this day within Metrorail about operators not having enough time off between shifts for adequate rest.

The NTSB report for this incident also once again raises questions about Metro’s organizational structure. The NTSB notes that Metro had made improvements following the 1996 crash, but that some of those changes were short lived:

WMATA’s organizational structure was not an issue in the November 3, 2004, accident at the Woodley Park station. However, following the 2004 accident, WMATA restructured its organization again, reverting back to the safety department having a disconnected responsibility and accountability reporting chain. In effect, this restructuring maneuver rescinded the direct reporting link between the safety department and the GM that had been established as result of the Shady Grove accident. This post accident reorganization could recreate the systemic information isolation that existed within WMATA prior to the Shady Grove accident, which in turn could inhibit serious safety problems from being identified or adequately addressed.

The NTSB would direct the Federal Transit Administration to assess Metro’s organizational structure, with safety recommendation R-06-04. This recommendation was marked as Closed-Acceptable Action in 2007. On July 14, 2009, Peter M. Rogoff, the FTA administrator, testified before a House subcommittee regarding the June 22, 2009 crash. In his testimony, Rogoff discussed R-06-04 as well as some more recent developments within Metro. From his testimony:

The FTA has conducted several SSO program audits of TOC since Part 659 went into effect on January 1, 1997. The most recent audit was conducted in October 2007. Previous audits took place in 2000 and 2005. FTA also conducted a Safety Review in 1997. The 2007 audit was conducted as part of FTA’s three-year audit cycle for all 27 SSO agencies in the audit program. During this audit, while on-site at TOC and WMATA, FTA also reviewed the progress made by TOC and WMATA to address two findings that were still open from FTA’s 2005 SSO Program audit of TOC. In addition, FTA used this opportunity to assess WMATA’s response to Safety Recommendation R-06-4 from the National Transportation Safety Board (NTSB), which addressed the adequacy of WMATA’s organizational structure and its ability to effectively identify safety issues. Prior to the Woodley Park-Zoo accident, the WMATA Safety Department reported to the General Manager through a Deputy. Shortly after, WMATA changed its organization so that the Chief Safety Officer and head of System Safety and Risk Management (SSRM) was a direct report to the General Manager. NTSB correspondingly classified this recommendation as “Closed – Acceptable Action”.

However, in recent months, WMATA has re-organized the Chief Safety Officer position to report to the Chief Administrative Officer, who reports to the General Manager. FTA asked the TOC to follow up with WMATA. WMATA has assured the TOC that the organizational changes do not adversely affect safety and that the “visibility and importance of the safety department will not diminish”. FTA continues to view the NTSB recommendation as a sound safety model and the current structure at WMATA causes us concern.

The 2006 Woodley Park crash illustrated, in a very vivid way, the potential for the catastrophic structural failure of Metro’s railcars in a collision. This has become the legacy of the incident, and less attention has been paid to the problem of operator attentiveness. The NTSB noted “the low task demands and unremarkable operating environment during the accident trip were conducive to the train operator becoming disengaged from some critical train operations.” This is a good example of multiple causes compounding to result in a serious incident.

To be clear, the prior collisions on the Red Line were not caused directly by problems with the Automatic Train Control system. The direct causes of both the 1996 and 2004 collisions were identified by the NTSB, and steps were taken by Metro to avoid re-occurrence. As discussed previously, Metro does have a good track record of addressing very targeted safety recommendations. It is very unlikely that the specific set of circumstances that caused the 1996 or 2004 collisions will happen again on Metro. However, that is not the larger issue. As the NTSB identified, there are organizational problems at play, problems that seem to be difficult for Metro to resolve.

The common thread that has emerged in this series is Metro’s reactive, rather than proactive stance on safety. Time and again there have been indicators that safety is not always the highest priority within the organization. The NTSB identified this as a problem, both in 1996 and again in 2004. In the wake of the 2009 crash, the Federal Transit Administration testified about continued concerns regarding Metro’s organizational structure. The fact that the safety department has been “overhauled” many times since the 1996 incident underscores the problem. A safety department that is in flux and experiences turnover at the highest level will likely not be able to instill the kind of work culture that is required for a complex organization.

In Part IV of this series, we will look more closely at the concept of a culture of safety.

Dave Stroup is an online organizer and progressive activist. He enjoys public transit, Democratic politics, and rabble-rousing.