Human error to blame for a close call between track workers and oncoming train, a Metro report says

Newly-published Metro safety investigation reports name human error and failures to follow protocol as common threads leading to close calls, injuries, and trains being sent down the wrong tracks. The reports say added training and better protocol adherence are among the recommended actions Metro departments should take to prevent these kinds of incidents from happening again.

The six new reports published by the Washington Metrorail Safety Commission (WMSC) on Friday, May 8 were submitted by Metro to the Commission, which adopted them at its March meeting. The investigations were performed by Metro’s Department of Safety and Environmental Management (SAFE) and sent to the WMSC for approval and span approximately one year.

Metrorail safety oversight has been the responsibility of the WMSC since March 2019 when it was certified and took over from the Federal Transit Administration. The FTA had stepped in to provide safety oversight temporarily after a string of safety and maintenance failures led then-Secretary of Transportation Anthony Foxx to take the responsibility away from the Tri-State Oversight Committee.

Precaution lapses lead to employee injuries

In one incident from August 2019, a Track and Structures (TRST) employee sustained third-degree burns to their foot while performing thermite welding to connect two pieces of rail near Huntington station.

“Slag [made] contact with [the] boot” when the employee’s foot “became wedged between an ATC bracket and the running rail in the area of the weld…the piece of the hot Thermite slag fell inside their boot through the open zipper…”

The Safety department found that the TRST Assistant Superintendent had the local work Supervisor take written statements from the crew, but instructed them not to report the incident, because they “did not think a level of severity was reached” for reporting.

They also faulted the crew for a messy work site with “tripping hazards and foot entrapment areas within the work location” as well as the crew’s management who “failed to oversee work operations to ensure personnel were following policies and procedures.”

Based on their investigation, SAFE told the Track department to enroll the Assistant Superintendent and Supervisor in additional training for how to conduct rail accident investigations, and the employee was enrolled in a course instructing on “proper body mechanics” which “can prevent slip trips and falls.”

Another employee suffered a second-degree burn to their hand and wrist in November 2018 when their coat sleeve caught on fire. The employee, in the Car Track Equipment Maintenance group, was cleaning an electric solenoid with a cleaner (No-Clean Flux Remover) when “the spray ignited.”

The employee was reportedly wearing safety glasses and their WMATA-issued jacket, but not the rest of the Personal Protective Equipment required by the cleaner’s Safety Data Sheet which notes it is “extremely flammable.” SAFE concluded the incident was the result of human error and the employee didn’t follow the required precautions for working with the cleaner.

Lack of verification leads to misroutes and close-call between track workers and a train

In a report from April 25, 2019, SAFE was brought in to investigate a Roadway Worker Protection violation during which a train sped past workers on the tracks at 40 mph instead of the 10 mph limit required by Metro safety protocols. The crew on the tracks was performing an inspection between Pentagon City and Crystal City, but entered the tracks before their Advanced Mobile Flagger (AMF), the employee in charge of notifying approaching train operators to slow down to pass track workers safely, was in place.

The WMSC is aware of an incident earlier today in which a train operator had not been notified there would be a work crew on the tracks. The WMSC has sought answers and an investigation, which the WMSC will consider at a public meeting in the near future. #wmata

— Washington Metrorail Safety Commission (@MetrorailSafety) April 25, 2019

Shortly before 10 am on April 25, 2019, the crew’s leader (RWIC) radioed in to the Rail Operations Control Center (ROCC) that they wanted to inspect the inbound track between Pentagon City and Crystal City rail stations. The RWIC told the ROCC their AMF was in place at Crystal City, the ROCC controller made an announcement on the radio, and the crew was given permission to begin their track inspection.

The AMF, however, was not actually in place, and the RWIC never contacted them over the radio to ensure that they were. The AMF told SAFE they called the RWIC on their phone upon arriving at Crystal City station to say they were there, but was still awaiting confirmation over the radio from the RWIC before setting up their flagging equipment. At the time Yellow Line train 308 stopped at Crystal City to open its doors, Metro CCTV captured the AMF away from the train and on their phone.

In their interview with SAFE, the RWIC stated that they “received confirmation via phone from their AMF that they were in place” before beginning their track inspection.

“The RWIC stated that their Watchman/Lookout, who was in front of the rest of the TRST Mobile Work Crew, started yelling ‘Hot Rail’ due to a rail vehicle speeding while the Mobile Work Crew was on the track. Due to the proper sighting distance being achieved, the Mobile Work Crew was able to reach a place of safety before the train passed them.”

SAFE concluded the close-call was “a result of human error and lack of procedural adherence from the RWIC” who “failed to receive positive radio communication from the AMF;” the train operator and AMF were cleared.

The RWIC was sent to a Roadway Worker Protection class for additional training. Metro’s rules regarding the use of an AMF require the RWIC to make communication with them over the radio and ensure that the AMF is in place with their flag and lantern prior to entering the tracks.

The WMSC also approved and published the Metro safety investigation from March 2019 in which three Orange Line trains were misrouted at Stadium-Armory towards Largo instead of New Carrollton. The investigation found no equipment malfunctions, but instead human error by ROCC controllers, train operators, and Automatic Train Control personnel. Two “Lessons Learned” bulletins were sent to the ROCC and to the ATC Maintenance group to act as reminders and highlight the need to adhere to procedures Metro already had in place.

Among the report’s findings, SAFE states the ROCC controller failed to align switches properly and set the correct routes in two instances for Orange Line trains to continue towards Minnesota Avenue instead of Benning Road; in the third, an ATC employee set an incorrect route. The controllers and train operators also failed to use the radio system to double-check each other and verify that the signals were set properly.

In two of the cases, the train operators failed to notice the incorrect signal - a flashing light, instead of a solid one - before proceeding down the incorrect track. Two of the three Orange Line trains were offloaded at Benning Road, while one was able to reverse back towards Stadium-Armory before proceeding normally towards New Carrollton.

In the third instance, an ATC employee with local control of the Stadium-Armory interlocking was using the wrong tool as a reference to keep track of which trains were approaching. The next train, an Orange Line train to New Carrollton, failed to appear on the ROCC Live Train Maps tool that the technician was using, and they ended up setting a route for the train behind which was a Blue Line train to Largo. The Orange Line train operator incorrectly proceeded past the signal showing a flashing lunar (indicating a route was set for Largo) and the train was then offloaded at Benning Road.

Equipment failures cause delays, smoke

An Orange Line train was offloaded at Smithsonian station on June 25, 2019 after the button used to close the train’s left-side doors failed and shorted, according to another report. The train operator was able to open and close the train’s doors from its third car, but not from the lead car where the operator typically sits. The investigation found the left-hand door close button shorted out, and was sending an errant electronic signal when it shouldn’t have been. The ROCC had the operator offload the train due to the door issue, and it was taken out of service to West Falls Church Yard.

While the failed button was the cause of the incident, SAFE also noted that the operator began troubleshooting the door issue and left the lead operating cab prior to notifying the ROCC as required. The operator was “re-instructed” on how to deal with a defective train.

The oldest new report accepted by the WMSC, from July 2, 2018, was triggered when a train operator notified the rail control center of smoke in the Capitol Heights station. Rail service between Morgan Boulevard and Benning Road was suspended while the Emergency Response Team, Prince George’s Fire Department, ATC, and Power crews responded to investigate.

The groups found smoke emitting from an AC power room and tracked it back to a fire which was located between power switching equipment and an automatic transfer switch which allows the source of electricity to be changed (i.e. whether equipment is fed from the power company or a temporary generator).

The report found that some cables, meant to be temporary and not used for longer than six months, had been in place for around 18 months, and there were no records showing they had been inspected. While SAFE and the power department were unable to determine a root cause, they state they believe that insulation on the temporary cables “at some point faulted, however, there is too much damage to pinpoint where.”

The report recommends future projects that require temporary generators use installation procedures as if the equipment were permanent, eliminating “the potential fault of exposed cables.” New cables should also be installed for projects so that a damaged or degraded one isn’t unintentionally used, and biweekly inspections should be performed.

While they act just as a snapshot in time of the rail system, the reports seemingly paint a picture of an improving, but still troubled, rail system. Oversight more often focuses now on ongoing human system safety concerns, which the agency can mitigate, rather than larger systemic issues which have subsided over the past several years.

The WMSC’s next public meeting is scheduled to be streamed online on May 12, 2020.