Should NTSB recommendations get a blank check?
Following the June 2009 Red Line crash that killed 9 people, the NTSB made several recommendations to Metro based on the causes of the crash. While these recommendations are obviously important, Metro has an obligation to riders, and to the families of the victims, to ask what safety trade-offs would be made by implementing them.
What safety trade-offs could NTSB recommendations possibly have? There are several potential causes of fatality and injury in the Metro system, and saying 'Yes' to the NTSB recommendations means saying 'No' to addressing other safety risks.
Based on the most recent WMATA Safety and Security Committee meeting, however, the WMATA Board appears poised to hand out blank checks for implementing any NTSB recommendations, without even inquiring into trade-offs. If that happens, the result for riders will be more budget shortfalls, leading to bigger fare increases, and unnecessary safety risks.
Here's what has happened so far. Metro announced in July that it has set aside $30 million over three years to implement any NTSB and FTA recommendations following the June 2009 red line crash that killed 9 people.
However, when Senator Mikulski (D-MD) asked in August for cost estimates of each recommendation, the total provided by Board chair Peter Benjamin was $100 million. And that's just for recommendations for which Metro has cost estimates.
When Chief Safety Officer Jim Dougherty met with the Metro Board on Sept 16, not a single question was asked about the skyrocketing costs and trade-offs of implementing federal recommendations.
Actually, not a single question was asked about the details or trade-offs of any of the recommendations, from the $55 million replacement of Gen 2 track circuit modules to the $25 million safety analysis of the automated train control system.
The oversight meeting with Dougherty lasted for only 45 minutes, and consisted primarily of a self-congratulatory presentation on the progress made by WMATA, which included the new logo seen here.
To exercise safety oversight, the Metro Board must ask about safety trade-offs in every meeting: Why are the current safety actions, whether they originate from the NTSB or not, the highest safety priorities?
The FTA asked this question during their audit and was told that no prioritized list of safety actions exists. The answer to the Board should look something like the table below. In fact, this should just be added to the monthly Vital Signs report.
This table is a Hazard Tracking Log (HTL). It's based on a similar table from a booklet called Hazard Analysis Guidelines for Transit Projects, published 10 years ago by the FTA. Lots of safety actions are prioritized based on the severity and likelihood of the identified hazard causing injury or fatality. Hazards and their corresponding safety actions are generated by 2 types of hazard analysis, reactive and proactive, which I describe elsewhere.
The non-NTSB recommendations in the table are empty because the Metro Safety Office has yet to conduct proactive hazard analysis for any critical system, as I've discussed elsewhere, and integrate the resulting safety actions into a prioritized list.
Most of the FTA's recommendations are focused on putting a Hazard Management System in place (basically, doing what the aforementioned booklet says to do) that consists of hazard analyses that continuously update the prioritized Hazard Tracking Log table. Metro's responses to FTA and NTSB recommendations, however, raise two serious concerns about its ability to put this System in place.
Metro is outsourcing hazard analysis of the Automatic Train Control system.
This $25 million, 3-year project, which is in response to an NTSB recommendation, was announced by Benjamin in his August letter to the Congressional delegation. That's a lot of money. $25 million would employ 75-100 engineers and analysts full-time for 3 years. One wonders what the WMATA safety office does if we are paying $25 million to contractors to do hazard analysis.
And what happens when the analysis ends, and we upgrade the automated train control system? Do we pay several million dollars again to a contractor to conduct another safety analysis? It seems like a good idea for the contractor to train and transition the safety analysis to WMATA's own safety office.
However, when asked if this would happen, a WMATA spokesperson responded, "The task will not specifically train Metro employees in how to conduct safety analysis, but will identify proper response and prioritization to safety concerns, particularly in an integrated environment."
Metro touts Hazard Management success without actually doing hazard analysis.
In Metro's August reply to the FTA audit, Metro merely copied the FTA recommendations (e.g. identify skills required for hazard analysis; train employees in these skills; etc) and pasted them into the HTL table shown above as a demonstration of progress.
Metro then announced triumphantly, "By evaluating the FTA recommendations in this manner, WMATA demonstrates that it has established a true hazard management program that incorporates a risk-based approach to evaluate and mitigate hazards".
This misplaced concern for the presentation of the results of hazard analysis, over the actual analysis itself, is even aired by WMATA's own IT department in the very same letter to the FTA. After discussing changes to the IT architecture being made to support hazard analysis, the following concern is said to be a "threat" to the entire project:
The System Safety and Environmental Management Department is awed by product suite success stories, dynamite product demonstrations and industry colleagues' evaluation of technology.The FTA should not accept the responses of WMATA to its recommendations until WMATA has demonstrated its ability to actually do a hazard analysis of a complex system, which would enable it to then prioritize hazards in a system. It doesn't really matter which system it is—
Metro can do this. It's my hope that, when the FTA begins regulating transit agencies, they will hold up Metro as an example for the rest of the country of world-class safety management.
But Metro can't do this and hand out blank checks for responding to NTSB recommendations regardless of the safety trade-offs. They are simply incompatible approaches to safety. The latter, reactive approach leads to budget shortfalls requiring fare increases, and to injuries and fatalities. The former, systematic approach leads to improved safety at the most efficient and rapid pace possible.
But Metro can only do this with leadership in oversight, particularly from Board chair Benjamin and Safety & Security Committee chair Mort Downey.
Kenneth Hawkins, brother of one of the killed passengers from the Red Line crash, asked following the NTSB hearing, "Who's going to hold WMATA accountable?" I still have the same question.
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