Photo by Mr.TinDC on Flickr.

Last Monday’s Metro incident left one person dead and many hospitalized. While the National Transportation Safety Board has confirmed that the smoke came from an electrical arcing event, there’s still a lot we don’t know about why passengers trapped in the tunnel couldn’t get out more quickly.

Initial reports indicate that while Train 302’s operator and DC Fire and EMS (DCFEMS) followed established protocols, poor communication within Metro and between Metro and DCFEMS caused the slow evacuation. Additionally, issues with the ventilation system may have worsened the smoke.

If we’re going to look at how effective and efficient both Metro and DCFEMS were in responding, it helps to have context for what an emergency response for this kind of situation should look like.

Emergency response took far longer than it should have

Metro’s procedures require that a train operator immediately report smoke or fire in the trackbed to the Rail Operations Control Center (ROCC). When this happens, ROCC is responsible for calling the fire department, which generally starts the process of getting emergency responders to the scene.

Fires along the Metro tracks are usually caused by the third rail, which provides the electrical power needed to move the train. Accordingly, Metro policy dictates that the ROCC shut off third rail power as soon as possible. However, Metro’s procedures do allow for ROCC to leave power on long enough to allow the train to retreat back to the previous station (if the operator is able to stop short of the smoke) or continue to the next station (if the train has already passed the smoke).

It appears that Metro may have left the third rail energized for so long because Train 302’s operator was trying, in vain, to return to L’Enfant Plaza

In addition to the workers at the control center, firefighters have the ability to manually disable power to the third rail by pressing a button on the blue light emergency trip stations, which are located every 800 feet along the tracks. But before firefighters can actually enter the trackbed, DCFEMS requires firefighters to get confirmation from the ROCC that the power actually has gone off.

Firefighters arrived at L’Enfant Plaza at 3:31 pm, nine minutes after Metro called to report heavy smoke in the station. By that time, the train had already been stuck in the tunnel for approximately 16 minutes. Another 13 minutes elapsed before ROCC confirmed that third rail power was off, though it appears rescue personnel entered the tunnel before that happened.

Communication was ineffective

Metro’s emergency response procedures require ROCC to coordinate all activities with a designated commander (usually Metro Transit Police) at the station. This designated commander must then coordinate with the fire department on the scene.

DCFEMS reports that their traditional radios were not working inside the station or tunnel, which made it difficult to communicate information about the location of the disabled train, the need for more help, and the status of third rail power. And while in this clip, the train operator is clearly in communications with ROCC, it does not seem that the ROCC was able to communicate with anyone at L’Enfant Plaza. These communication failures likely slowed and limited the effectiveness of the emergency response.

The train operator didn’t evacuate the train immediately

Because the train operator was able to stop the train short of the smoke, Metro’s procedures called for him to retreat back to L’Enfant.

Since the tunnels can be dangerous places, it’s obvious why Metro wants evacuation, especially without rescuers on scene, to be a last resort. But if retreating is not an option, train operators can evacuate passengers into the tunnel after receiving authorization from the ROCC; they don’t have to wait on firefighters to arrive.

Several videos have captured audio of the train operator assuring passengers that he would return the train to the L’Enfant Plaza platform, where they could alight. But that wasn’t an option because another train that couldn’t move (possibly because the train operator had evacuated the station) was already on the platform. And even if the other train hadn’t been there, it’s possible that a lack of third rail power or passengers leaving the train on their own would have prevented an attempt to return to the station.

Firefighters eventually evacuated those who didn’t self-evacuate though the tunnel. Metro Transit Police reported via Twitter that evacuations were complete an hour and 30 minutes after the first reports of smoke.

One firefighter has speculated that more people didn’t leave the train cars on their own because the emergency door releases on the 3000-series cars are hidden.

Measures to clear the tunnel of smoke either didn’t follow protocol or didn’t work

ROCC didn’t cut power to the part of the third rail where the arcing event occurred until 35 minutes after the train was stranded in the tunnel. During this time, the arcing continued, and continued to generate smoke. If ROCC had cut third rail power shortly after the train became stuck, it’s possible that there would have been much less smoke since the arcing would have stopped.

Only a minute after the train operator stopped the train in the tunnel, ROCC did activate Metro’s exhaust fans, which can clear smoke inside of a station or tunnels. But these fans may not have been functioning properly when responders first arrived at the scene.

Nobody could have prevented harm altogether, but Metro has a lot of room for improvement

It’s unlikely that any response would have gotten riders out unscathed. Even passengers who quickly evacuated from the platform at L’Enfant Plaza had to be treated for smoke inhalation. But Metro’s response likely depended too much on getting the train back to L’Enfant Plaza even when it became obvious that that strategy was becoming futile.

It will likely be six months to a year before NTSB officials release their findings on last Monday’s incident (though they did release a preliminary report). On Saturday, Mayor Muriel Bowser released an initial report on DCFEMS’s response.

It’s already clear that Metro could have done better. Hopefully, new procedures and better safety training will come out of this tragedy. But it’s a shame that this wasn’t prevented in the first place.

Kelli Raboy works as a federal contractor supporting research on vehicle automation and communications. She loves all things cities, public transit, and rail. She lives in Navy Yard.