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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.

Hazard Tracking Log (HTL) Should be Added to Vital Signs.

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—the elevators, the train doors, even the payroll system would be fine.

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.

Ken Archer is CTO of a software firm in Tysons Corner. He commutes to Tysons by bus from his home in Georgetown, where he lives with his wife and son. Ken completed a Masters degree in Philosophy from The Catholic University of America. 


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Maybe my memory is serving me incorrectly, but hadn't the failed track circuit module that cause the Red Line crash been replaced just several days prior to the incident?

by andrew on Sep 30, 2010 2:05 pm • linkreport

No. The module had not been replaced. The impedance bond had been replaced. It was made by a different company than the module.

by Matt Johnson on Sep 30, 2010 2:21 pm • linkreport

You say "trade-offs" about twenty times but I don't see much explanation of what they would be. Other than near the end when you reference injuries and fatalities without explaining what mechanism would lead directly to them.

by Lou on Sep 30, 2010 2:33 pm • linkreport


Aha. Got it. Makes sense...

by andrew on Sep 30, 2010 3:28 pm • linkreport


Are the track circuit modules the only safety critical system in Metro? What about the train subsystems like the brakes? What about the elevated tracks (a Chicago train fell off its elevated track a couple decades ago)?

Then there's the WMATA worker fatalities. Have we done anything other than issue a new manual for track workers? Do we have a list of things that could be done (irrespective of costs) to better protect track workers?

Then there's the bus collisions. Do we have a list of things that could be done to improve the bus safety record and reduce the chances of bus fatalities?

We don't know what the trade-offs are because Metro is in reactive mode, focused on preventing the causes of previous incidents without anticipating the causes of the next incident.

by Ken Archer on Sep 30, 2010 3:31 pm • linkreport

Ken, I just don't see such a direct cause and effect relationship. You say that saying yes to the NTSB recommendations means saying no to other things.

I think what you've written here does a good job of pointing out that Metro has failed to enumerate and prioritize overall system safety. But it seems to me that fact precludes any finding of a trade-off, because you can't say A-for-B.

by Lou on Sep 30, 2010 3:54 pm • linkreport

Metro needs a full restructuring. When there are budget problems, terminate back office employees.

by Sag on Sep 30, 2010 4:08 pm • linkreport

Echoing comments by others, you cite trade-offs but dont find them... all vigor, no solutions provided.

Agreed Metro needs a full review and restructuring. It would help if Metro was even more transparent about where the money was going both now and for the planned Fiscal Years.

Let the sunshine in!

by L. Fairfax on Sep 30, 2010 9:19 pm • linkreport

The reason why I don't provide specific trade-offs is because no one knows what hazards exist in the Metro system other than the specific hazards identified by various NTSB analyses of specific accidents.

The causes of the next accident causing fatality or serious injury are statistically unlikely to be the same as the cause of the Red Line crash. That's why the FTA has been demanding that transit agencies do proactive, systematic analysis of hazards before they lead to accidents.

Furthermore, much of the FTA's desire to regulate transit agencies is due to these agencies' unwillingness to do this type of analysis that would uncover the causes of future accidents.

This is standard practice in airlines, many defense sectors like jets, and other safety critical industries. It will eventually happen in transit. It would be great if Metro was a leader in this transition, and not a laggard that is dragged by the FTA.

by Ken Archer on Sep 30, 2010 9:39 pm • linkreport

Many Metro employees know many of the hazards that exist, but the issues are dismissed and the empolyee labeled a troublemaker.They sweep issues under the rug. As mentioned Metro is reactive and management doesn't understand the problems because they don't have the field experience. Unfortunately, the most competent employees will retire soon and a void of knowledge will exist. Metro needs to value the knowledge and experience of senior field personnel.

by Grace on Oct 1, 2010 10:03 am • linkreport


You summarized the problem very well.

The good news is that we do have an oversight board that has told NTSB without hesitation that they want to oversee safety. Let's hope that the board, particularly Benjamin and Downey, start making the excellent points you just made when Metro execs testify at their meetings.

by Ken Archer on Oct 1, 2010 10:12 am • linkreport

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