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Lessons not learned: The Tenleytown escalator failure

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.

Photo by brownpau on Flickr.

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.


Lessons not learned: WMATA misinterprets FTA safety program and blames workers

In December, WMATA began issuing new circulars to employees called Lessons Learned. The purpose of Lessons Learned is to describe safety issues that have occurred as well as the steps being taken to prevent future occurrence. Three have been issued thus far, and GGW received copies from one of the recipients.

A Metro "Lessons Learned" Circular

While well-intentioned, the Lessons Learned program illuminates the struggle WMATA management is having with their own employees. The circulars make clear that management really learns the same single lesson after every incident: their employees don't follow rules.

WMATA is doing these Lessons Learned circulars because the FTA told them to in their audit. But WMATA is missing the point of the FTA program.

The purpose is not to berate workers with the "lessons" they should learn from these incidents, but to educate management about the lessons they should learn about how the agency responded.

The FTA explains the Lessons Learned program as follows in their audit:

While such programs are not generally considered a part of training, they can be of exceptional value in educating management. Lessons Learned programs address the agency's response to problems that have occurred and been dealt with in the recent past. The salient issues are identified and managers and other other personnel are encouraged to critically review the way the agency responded.
In other words, the lessons learned from causal analyses of incidents are lessons for management. That's because the root causes of safety and performance lapses, as most texts on safety and quality management make clear, "are underlying, are reasonably identifiable, can be controlled by management and allow for generation of recommendations."

In announcing the program to WMATA staff via email, however, GM Sarles already concludes that the relevant lessons are not for management but for front-line workers.

I want to call your attention to the new circulars being issued by SAFE called Lessons Learned. These brief handouts clearly describe safety issues that have arisen on our system or other systems and point out how to prevent recurrences. The circulars remind us of the importance of safe work practices, as well as the need for unwavering attention to safety rules and regulations.

At the end of the day, learning from others' experiences can help prevent injuries and save lives. I applaud the work of SAFE and our labor partners to provide this information to all employees and recommend that everyone read the first three circulars that have been issued http://metroweb/safety/lessons_learned/default.aspx.

We will look at specific Lessons Learned circulars in future posts. The first Lessons Learned circular that we will look at concerns the removal of a barrier from an escalator at Tenleytown that had 3 steps removed for maintenance.


Should the FTA regulate urban transit agencies?

Imagine if Metro had to pay a fine for every safety standard violation. What if Metro officials and operators lost licenses to work in transit if they repeatedly violated safety standards?

Photo by atomicfamily on Flickr.

These ideas could become reality if the FTA gains the ability to regulate public transit agencies. And while many Washingtonians regard this as a no-brainer, there are serious concerns that few are considering in the post-Red Line Crash fear-mongering.

The standard argument in favor of FTA regulation is that regional safety oversight bodies are simply too unprepared and ill-equipped to assure safety on America's transit systems.

These bodies, like the Tri-State Oversight Committee which provides safety oversight of Metro, have little to no staff and no enforcement powers. The DOT oversees safety on Amtrak, so why not subway and light-rail systems too?

While this standard argument is compelling, there has been little engagement with the counterargument to federal oversight of urban transit. Consider the following concerns.

Urban rail is very safe: Subways and light rail are already very safe, safer by far than other modes of transportation that are regulated by the DOT including air travel. One wonders then if improving on an already very low fatality rate should be a priority for federal dollars given the other more dangerous modes regulated by the DOT.

The TOC can be improved easily without federal intervention: The criticism leveled against the TOC is not directed at their competence, but at their lack of enforcement powers and funding. So, instead of building a new federal agency, why not give the TOC enforcement powers and increased funding?

TOC audit was actually better than the FTA audit of Metro: While it received little press attention, the TOC audit released earlier this month was more detailed and actionable than either the NTSB or FTA audits concerning the systemic safety hazards at Metro.

Federal urban rail regulation may be unconstitutional: Federal regulation of urban transit systems may ultimately be overturned by the courts. The Commerce Clause of the Constitution limits federal regulation to interstate commerce, and most urban transit systems don't cross state lines like Metro does.

NTSB previously opposed FTA oversight of urban rail: Every urban transit system is very different, despite appearances to the contrary. Unlike other transit modes regulated by DOT which share a common network, urban transit systems develop independently according to unique needs and constraints. The NTSB argued in the 90s that this was reason enough to support the regional system of safety oversight in place today.

For these reasons, I would strongly oppose FTA regulation of Metro and other urban transit agencies if not for one prominent benefit that would result from FTA regulation:

FTA can balance NTSB: While the NTSB serves a valuable role in transportation safety, they are an exclusively reactive organization by statute. Unfortunately, the political pressure to implement any and all NTSB recommendations is overwhelming. This undermines attempts to create a proactive safety organization.

The USDOT, which requires transportation providers to take a more proactive approach to safety, balances the NTSB in the transport modes that it regulates. This balance will never be provided by the TOC or other regional safety oversight bodies.

I am honestly on the fence on this critical issue. While the answer to this issue seems obvious to many, I suspect that the damning of all things Metro since the Red Line Crash is undermining the healthy debate that this issue deserves.

The Obama administration supports a bill that would give the FTA this power, but Senator Tom Coburn (R-OK) has put a hold on the bill in the Senate for many of the reasons listed here, as well as the lack of offsetting spending cuts or taxes in the legislation.

What do you think? Should the FTA regulate urban transit agencies?


Metro safety presentation still doesn't prioritize

WMATA will hold its first meeting of the new Safety and Security Committee tomorrow, split off from the previous Customer Service, Operations and Safety Committee. The staff presentation still needs more information to help the board oversee safety, including a sense of priorities.

Photo by the|G|™ on Flickr.

The presentation lists the status of NTSB recommendations and the cost to complete each. That is helpful, but doesn't provide any information about what vulnerabilities each recommendation fixes, and what criteria the staff used to prioritize.

The recommended fixes range from the relatively inexpensive ($350,000 for "Improve Internal Communications") to the cost-prohibitive ($835M for "Removal of 1000 Series Rail Cars").

Metro also provides information about the operating divisions that have the most days without a lost time injury, highlighting their best performance. It is a good idea to commend those divisions for maintaining safe work practices and keeping their workers safe. But for a board oversight role, it would be more instructive to show the operating divisions with the worst safety record, and show what are the findings from safety assessments or the results of incident investigations into the injuries.

Metro should look at their best performing divisions as a source of best practices to transfer over to other divisions where workers have been injured. Rather than highlight their best performance, Metro and its oversight board should be looking into their worst performance in order to improve it.

In my opinion, the least valuable part of this presentation is a series of 10 bar charts showing the number of various types of incidents in 2009 compared to 2010. Metro shows that the "2009 Average" rail passenger injury rate was 0.47 per million passenger trips, and that the 2010 injury rate to date is much lower, at 0.14.

This allows the casual reader to think that Metro is somehow improving. But the previous year had the worst accident in Metrorail history, and should not be used as a sort of "average." Instead, Metro should treat every accident as undesirable, and avoid showing averages unless they are based on the long-term average rate over the past decade or a similar time period.

Given these charts showing incident and injury rates varying over 16 months in the past, what is the board supposed to do? There isn't any analysis given, only data. Are a lot of the injuries preventable? Are they related to the NTSB findings and therefore the money to be spent on fixes would help the incidents Metro is experiencing? Is there some other fix that would help to prevent these incidents?

Metro is showing data about the injury rate, but there is no explanation about why the rates are increasing or decreasing. Maybe this will be part of the discussion, but so far it doesn't look like Metro has dug into what the problems really are.

Compare this with the discussion about Elevator and Escalator repair. Metro had to call in an assessment consultant to find its problems, and plans to re-hire the same consultant to figure out whether the corrections have stuck. This indicates that at least in some areas, Metro has lost the ability to assess its own performance, and must rely on outside organizations like consultants, the NTSB and the TOC to find its problems and recommend fixes. One of Metro's goals should be to develop a culture of self-assessment, so that the organization can better find problems itself without relying on outside help.


Metro audit portrays isolated safety management

A new audit of Metro's safety found that operational departments still need to be more deeply involved enough in safety, and that safety officials need to focus more on small incidents in addition to larger ones.

Photo by boogah on Flickr.

This audit, conducted by the Tri-State Oversight Committee and released this week, takes a closer look at Metro safety practices than before. While the FTA's audit, released in March, revealed systemic concerns such as the lack of a Hazard Management System, the nearly 300-page TOC audit reveals the specific deficiencies of such systems.

Metro riders should take some comfort that this in-depth audit was conducted and made public. The Board, media and public should make sure that each "deficiency" and "area of concern" revealed by the audit is addressed.

The TOC audit portrays the safety management within Metro (known as SAFE for System Safety and Environmental Management) as an island, isolated from the departments whose processes and procedures SAFE is charged with continuously improving.

For example, SAFE's manual of operating procedures (Safety System Program Plan, or SSPP) apparently bears little relation to what workers actually do, because other departments aren't included in writing or revising these procedures.

p 64. Area of Concern 4-1. Non-SAFE departments and the ELT are not engaged in updates to the SSPP. WMATA did not solicit the review and comments of the other WMATA departments to which the SSPP applies, per the lessons learned from the December 2009 Internal Safety Audit conducted by APTA. Thus, the descriptions provided within each element of the SSPP do not fully represent the processes and documentation used by the non-SAFE departments in implementing the SSPP.

The island move further from the shore when hazard analysis is conducted, as SAFE ignores reports of hazards from most sources.

p 78. Area of Concern 6-6. Too few sources provide input regarding hazardous conditions. Primary input of hazardous conditions to SAFE comes from the OCC [Operations Control Center]. SAFE needs to expand the sources of hazardous condition reporting to include inspections, audits, investigations, observations. hotlines, etc.

This is very consistent with the complaint amongst Metro workers that the organization won't do anything about reported safety hazards.

SAFE is primarily reacting to major accidents, not getting out ahead of the next accident. This reactive position is only hardened by the enormous pressure to respond to NTSB recommendations, all of which are reactive preventions of the causes of previous major accidents. TOC criticizes this reactive posture, as have I on multiple occasions.

p 79. Area of Concern 6-9. Hazard management does not include smaller incidents. The trending and analysis of multiple, less serious, incidents or near misses is not currently being accomplished.

Some portion of these issues are being addressed by Metro, with new hires and training in SAFE, all of which are mentioned by TOC.


What should we expect from elevators and escalators?

An audit confirmed what most riders already knew: Metro's escalators and elevators are not working like they should. The audit identified a number of places where maintenance processes and training could do a better job for maintainance and repair of escalators and elevators.

Photo by afagen on Flickr.

The audit itself hasn't been released, but according to Assistant General Manager Dave Kubicek's summary of the audit the major issues are an unbalanced preventative maintenance schedule, a shortage of supervisors, water intrusion, and insufficient training of workers on the Maintenance Management System (Maximo).

But let's not jump to the conclusion that the Post's headline writer originally did, who labeled Ann Scott Tyson's writeup, "Report says Metro failing on escalator repairs" before changing it to the more sensible "Escalator audit highlights deficiencies."

It's not the scandal of the year that the escalator maintenance program isn't perfect. In fact, riders all pretty much could tell that already. Any big organization has flaws like this. A good one tries to root out and address those flaws, and now that Richard Sarles is running WMATA (for the time being), the organization is making strides in this area.

Just identifying the problems is the first step. Now, the Board and riders need to measure whether they are being addressed and whether such steps are actually improving escalator and elevator performance.

Thanks to Metro now releasing a Vital Signs Report each month, we know that escalator availability has been hovering around 90% and elevator availability around 96%.

What level of availability should riders reasonably expect once these maintenance procedures are fixed? Are the targets set in the Vital Signs report of 93% escalator and 97.5% elevator availability the right targets, and will these changes get us to these targets?

1 out of 14 escalators out of service may be a significant shift in expectations for riders. And the target for elevator availability would actually mean Metrorail availability of 90% for riders with wheelchairs and strollers, since each trip requires 4 elevators and these riders can't take escalators or stairs.

Once targets are agreed upon, there needs to be a clear link between these targets and the investments required to meet them. There's lots of good ideas for improving availability, like the "team-building initiative to enhance communications among staff and improve the team's effectiveness" that the current Vital Signs report commits to.

But we need more than good ideas. What will it take to actually reach availability targets? And how do we know?

The main proposal put forward by the audit requires increasing scheduled maintenance intervals. But maintenance requires taking escalators out of service, and Kubicek says in Vital Signs that this is the cause of some lack of availability. At what point does the downtime of increased maintenance outweigh the unscheduled downtime that this maintenance prevents? Can any of the inspections conducted during routine maintenance be done with remote sensors (detecting water, vibration, heat, etc)?

Also, as David pointed out in an interview on Fox 5 (embedded below), there's another factor behind escalator problems: resources. The system was new in the 1970s and 1980s, and escalators and elevators needed little repair. Now they need more repair, but budgets still are underfunding ongoing maintenance like this. And at least so far, the Board has been showing an unlimited willingness to spend money on safety fixes without regard to cost, but may continue to shortchange other needs.

A smart General Manager would announce to the Board and, by extension, to the media: We're at 90% now. We've found these internal issues and will fix them. These contribute to (say) 20% of downtime so that will get us to 92%. If we allocate some of our capital dollars to escalator repair, we can get to (say) 96% by addressing additional causes of 40% of downtime.

Soon, the public will be invited to comment on WMATA's Capital Improvement Plan, a multi-year priority list of where to spend limited capital dollars. Much of that rightly ought to go to safety, but there will be a danger of putting too many eggs in that one basket. If we really want escalators to be working, which by the way has safety implications of its own, we will need to send a message to the Board to be sure to allocate some capital dollars to repairing and replacing escalators.


Metro workers afraid to report hazards, Board unfazed

Some 30% of Metro employees don't report safety hazards for fear of retaliation. That's according to testimony from Metro General Manager Sarles at the most recent Metro Board meeting, which included the results of an employee survey of Metro's safety culture.

Metro Board Chair Peter Benjamin.

If that isn't alarming enough, the response of the Chair of the Metro Board will be. Board Chair Peter Benjamin effectively blamed the workers for their perceptions.

According to General Manager Sarles:

Approximately 60% of those surveyed said that they have observed a safety-concerned violation in the past year while on the job at Metro. This is concerning. But we also learned that of those observing concerns, approximately 70% are reporting their concerns with their first reporting channel being their supervisor.

That means that 42% of workers (70% of 60%) have reported a safety hazard in the past year. That's alot of safety hazards reported. That also means that 30% of safety hazards noticed by workers aren't being reported. Sarles then addresses the latter issue of fear of retaliation.

There is a strong concern about retaliation but in somewhat unexpected ways. Employees' primary concerns are not that they would be fired or demoted. The strongest concerns that were cited were that it would be difficult for them to work among their peers, that the organization wouldn't do anything about their report, and that the organization would not protect them against retaliation in their immediate working environment.
So, imagine that you are the Chair of the Board at this point. The NTSB has excoriated your Board for its lack of safety oversight following the Red Line crash that killed 9 people. Everyone is pushing Congress to let the FTA regulate transit agencies because of your Board's failure in oversight.

You have responded to the NTSB and FTA by saying that you are now up to the task of safety oversight, and are modifying your mission statement in the very same meeting to place more focus on safety.

You would probably ask if the workers are correct that the organization wouldn't do anything about their report. What does the organization do with reports of safety hazards, and is this process documented and audited? What has it done with the safety hazards reported by 42% of workers?

Board Chair Benjamin:

My reaction is that your report is impressive, it's thorough, it's in-depth, it's exhaustive, and more than anything else it shows your leadership as a General Manager, and the combined efforts of a really dedicated senior staff, middle management and staff throughout this authority. It's an extremely, extremely good report.
Huhh? What is "extremely, extremely good" about 60% of workers noticing safety hazards and 30% of workers fearing retaliation if they report safety hazards?
I would like to comment very briefly on the employee survey because it's such an interesting set of results which reflect not necessarily reality but perception. And in this particular case, perception is so important. Because if what you are trying to do is revamp your culture, you have to know where you're starting.
So, after lauding praise on management, Benjamin dismisses the workers' perceptions as "not necessarily reality" and shows absolutely no interest in what has been done with the safety hazards noticed by 70% of workers and reported by 42% of workers.

This meeting exemplified the dangerous rut that Metro is in: (a) writing blank checks to demonstrate its response to NTSB recommendations designed to prevent a crash like the Red Line crash, while (b) placing their heads in the sand when anyone suggests that more safety hazards exist.

What exactly is the Board doing any differently than they did before the Red Line crash to demonstrate safety oversight?

Other than reviewing statistics of injuries and fatalities by month (which we all knew by reading the newspaper anyway), forming a Safety committee and changing the mission statement, it's unclear what is happening that is supposed to resemble safety oversight.

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