Photo by brownpau on Flickr.

On November 16 at 4:11 pm, a worker at the Tenleytown Metro station moved a barricade from an escalator that was out of service for brake repairs. 16 passengers subsequently walked up the escalator only to find 3 removed steps.

After safely traversing the 4-foot hole, another passenger placed an orange cone found nearby in front of the escalator at 4:15 pm. At 4:19 pm the barricade was returned to the escalator.

As discussed last week, WMATA has misinterpreted the FTA’s recommendation to analyze causes of safety incidents and circulate lessons that the agency can learn. Instead of using them to find real root causes, they’re using the Lessons Learned circulars to berate workers for not following rules.

The incident of the moved escalator barricade at Tenleytown is one of the first incidents to receive this Lessons Learned follow-up from the safety department at WMATA.

Certainly the worker did not follow the rules or common sense in removing the barricade from the out of service escalator. WMATA used the Lessons Learned circular to criticize this.

However, real analysis of safety problems involves not just looking for the most evident failure, but digging deeper.

  1. Why did people try to walk up an escalator missing steps? Because the worker moved the barricade.
  2. Why did the worker move the barricade? Because he needed to restart another escalator that had also gone out of service, and there were no other barricades. 2 of the 3 escalators were now out of service, and rush hour was just beginning.
  3. Why were there no other barricades? Because there are not more barricades available at stations.
  4. Why are barricades needed? Because workers need to alert passengers about any out of service escalator before performing work on it.

Should he have moved the barricade? No. But does lecturing workers on not moving barricades do anything to prevent this from recurring? No.

If you stop at the first step, the conclusion is to tell workers not to move the barricades. But if you continue the chain to the end, the real Lesson Learned should be that WMATA needs to provide some means to alert passengers about any out of service escalator, regardless of the number that are out of service at any station. For example, every station manager or escalator worker could have yellow or red tape to place across the escalator opening.

The even deeper lesson learned for management would probably be this: when management doesn’t resource workers properly, they are forced to choose between following rules and doing their jobs.

Instead, the Lessons Learned circular lists 3 “Contributing Causes” and 2 action items for “Preventing Recurrence” that generally berate the worker for breaking a rule.

The first contributing cause, “There was no way to secure the barrier to the escalator,” is not a contributing cause at all. It’s just someone skipping the causal analysis to say what they think should be done to keep workers from breaking rules. And sure enough, the first action item is that “ELES is researching an attachment that will allow the barrier to be clamped to the escalator.”

If the barrier had been clamped to the Tenleytown escalator, then the entire rush hour would have seen 2 out of service escalators, with the only remaining working escalator going down.

The second contributing cause, “The out of service status of the escalator should be clearly communicated to all employees,” makes no sense. This is a recommendation, not a cause. And it would also change nothing.

The third contributing cause, “No one should remove or alter a safety device before first ensuring it is safe to do so,” is again not a cause, but a rule. The rule is then repeated at the conclusion of the circular.

The only other action item for preventing recurrence is this: “Signage will be improved and a redundant barrier located near the work area is being considered.” WMATA should do more than just “consider” providing a barrier, even if only red tape, for every escalator.

What is the point of Lessons Learned if it involves scolding employees for breaking rules, while management only has to “consider” rectifying the deeper cause.

The central challenge facing WMATA’s efforts to improve safety and reliability is its inability to conduct causal analysis when systems fail.

The Lessons Learned program is a vivid illustration of this inability. General Manager Sarles is to be commended for putting the

program in place. Given how the safety department has executed on the program, though, Sarles and the WMATA Board should insist that it change course to demonstrate the causal analysis that the FTA intended.

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.