Image by Elvert Barnes licensed under Creative Commons.

Harassment, confusion, fatigue, short-staffed, ill-trained. A new audit of the Metrorail Rail Operations Control Center (ROCC) lays bare ongoing issues at the nerve center of Metro’s rail network, and with it, some of what Metro needs to do to begin to fix it. Recent Metro actions have shown “promise,” but what will it take to turn the department around?

The Washington Metrorail Safety Commission (WMSC), in charge of safety oversight of DC’s passenger rail system, issued on Tuesday a new report detailing major issues at the ROCC, the latest in a long-running series of reports and investigations centering around the facility. The commission identified 21 major findings, and is requiring Metro to come up with Corrective Action Plans (CAPs) detailing how the transit agency plans to make progress and fix them.

The findings in the new WMSC report primarily result from the culture of the building and a history of inaction: “Despite fatal accidents such as the 2009 collision near the Fort Totten Station and the 2015 smoke accident near the L’Enfant Plaza Station, numerous National Transportation Safety Board (NTSB) and Federal Transit Administration (FTA) reviews, and other investigations, reports and audits that repeatedly raised alarms, this audit demonstrates that still, in 2020, Rail Operations Control Center (ROCC) management has not created an effective safety culture.”

Metro has 45 days to respond to each of the 21 findings in the new WMSC audit with a plan to fix the issues identified, the person or persons responsible, and the estimated date for when the issues might be fixed.

This post is the first in a series that aims to dive deeper into the issues found by the WMSC ROCC audit.

A brief history of ROCC oversight reporting

The ROCC is a critical piece of Metro’s rail network. Controllers in the building direct train movements, coordinate with maintenance crews for turning on and off third rail power, fans, and other equipment, work with a fire department liaison, and send alerts to riders. “It is integral to the safety of riders, workers and first responders,” the WMSC says.

But the department has serious, long-running, deep-rooted issues: “Yet the control center’s environment includes distractions, fear, threats and conflicting instructions that prevent overworked and undertrained controllers from fully and properly carrying out their duties. These serious safety concerns create a variety of safety risks for everyone who depends on Metrorail.”

Issues at the ROCC are not new, by any means - the new WMSC report cites a 1982 document from the National Transportation Safety Board (NTSB) which “recommended that Metrorail eliminate the practice of issuing verbal instructions in the ROCC that modify or amend operating rules and standard operating procedures.“

More recently, a 2015 safety management inspection performed by the Federal Transit Administration identified a number of issues - many of which overlap with the WMSC’s new report. The FTA issued 54 findings out of that report relating to everything from ROCC understaffing to fire/emergency preparedness to system-wide maintenance issues.

Recent events caused the WMSC to turn its attention to the ROCC and led to the oversight commission speeding up this audit. The first event from December 10, 2019, “had many similarities to the fatal 2015 accident near L’Enfant Plaza Station nearly five years earlier,” the WMSC says. In the incident, a train approaching Tenleytown stopped in front of and reported a fire on the tracks. The train arrived back at Friendship Heights more than 50 minutes after the train operator reported the fire.

The WMSC found that “dysfunction” in the ROCC, conflicting instructions, and a failure to use checklists limited the ROCC’s ability to “appropriately and effectively” manage the emergency situation.

After issuing the December report, the WMSC then issued another on May 12, 2020. The May report includes three serious issues which they’re requiring that Metro fix. Rail controllers didn’t have the necessary training to use the tunnel ventilation fans throughout the rail system, controllers were instructed to disregard safety precautions and re-energize third rail power before it was safe, and ROCC management interfered with the computer systems that rail controllers use.

Brief overview of all issues

The WMSC issued 21 findings for Metro to address in its audit of the rail control center. The findings themselves summarize issues which the WMSC deemed important enough to make note of, and thus require Metro to do something about them.

Between the 21 new findings, the WMSC grouped them into 12 categories, some of which overlap with each other and have been condensed below.

The ROCC still lacks a culture of safety

One main takeaway of the new WMSC audit is that the ROCC still lacks a culture of safety. The audit highlighted a number of critical issues at the ROCC impacting new and old employees of nearly all job functions inside the department.

The current culture is “toxic and antithetical to safety and other standards,” according to the WMSC, and they want Metro to fix that.

The “highest levels of ROCC leadership” have instructed controllers to ignore procedures and checklists, the WMSC says, and those senior leaders have violated procedures themselves. Checklists, like those used in air traffic control and other fields, are critical items which can ensure that steps aren’t missed during emergency situations.

Controllers told the WMSC that emergency responses can be chaotic, and that some have been threatened with “arrest or termination for following procedures or asking questions.”.

Harassment and threats

ROCC rail controllers have reported sexual, racial, and even some physical harassment. Controllers told WMSC staff that other officials yell and curse at their workstations and some controllers have been “baselessly threatened…with arrest or termination for following procedures or asking questions.”

One controller is quoted in the report as saying “When management comes down to the console, they talk [to] you any old way. They yell. They curse.”

Investigation interference

Metro wasn’t able to provide the WMSC with policies that showed its own safety investigations were completely separate from the employees being investigated.

In some cases, event descriptions were passed up through management employees, not the actual personnel involved in incidents. In other cases, the safety investigators relied on audio and video clips provided to them by ROCC staff, rather than getting that information separately.

The WMSC noted its concern that existing lax policies could allow files needed for investigations to be “edited, redacted, or manipulated” by those involved.

Emergency communications failures

Employees in the ROCC don’t all know what the fire liaison, someone who sits in the ROCC and communicates with fire departments around the region, does.

Metro has also staffed the fire liaison position during the Coronavirus pandemic with officials who didn’t receive training for the job or protocols they would need to follow.

At least one policy Metro has in place assumes that when a station manager reports smoke or fire that it should be treated like a false alarm, rather than an actual emergency, while the source is investigated.

The ROCC is severely short-staffed and turnover is high

As of July, 2020, Metro told the WMSC that they have 30 certified rail controllers. The agency also noted it needs 50 rail controllers to run the rail system with the addition of the Silver Line Phase II out to Dulles Airport and Ashburn.

The staffing shortage results in some controllers working significant amounts of overtime to fill the gaps, which itself could lead to tired employees making critical errors.

A significant percentage of controllers turn over every few years, both during initial training and after having taken the job. In interviews, the WMSC learned training doesn’t match job expectations, the environment is hostile, and trainees found they faced “conflict” on the job and sensed others “…are rooting for them to fail.”

Rail controllers are working more than allowed, breaking fatigue policies

Some Metro rail traffic controllers have worked far more hours than they’re allowed to by Metro policies, but ROCC management seem to have turned a blind eye to policy violations since the building is so understaffed.

The WMSC found instances where some controllers worked 10 or more days in a row, far more than allowed. In one case, an employee worked lengths of 26, 28, and 29 consecutive days during April, May, and June.

Metro policy says employees can’t work more than six days without 24 hours off, or 48 hours off if they work seven days.

Training deficiencies

Training for both new and old employees alike is insufficient. Class-based training, according to controllers, is completely different then what they’re expected to know while on the job.

Trainees waste time during training as well. According to one, “We don’t do much in the training in the first half of the day, and didn’t do much after lunch.”

The training classes, according to the WMSC, are inconsistent, and different controllers have been taught different things depending on when they were taught. Similar inconsistencies exist in certification for ROCC instructors and superintendents.

Outdated procedures

Protocols seen by the WMSC haven’t been updated recently, even though there’s a process set up for periodic reviews. One of the procedures was last updated in December 2016, although no updates had been made to the existing September 2013 version.

“Failure to review SOPs and OAPs that form the basis for critical operations runs the risk of missing safety hazards or creating conflicts among SOPs or other procedures that have been updated, such as the Roadway Worker Protection program,” the WMSC audit noted.

Ride alongs

ROCC rail traffic controllers are supposed to be able to walk on the tracks and get on-site experience on a regular basis, but the visits aren’t working as expected.

Rail controllers reported occasions where they were either left to sit on station platforms while the crews they were assigned to did their work, or told to sit in a car for hours.

Prior audits of the ROCC found controllers were unfamiliar with the tracks they were dispatching for and they hadn’t been given the chance to learn; those audits directed Metro to ensure controllers were performing their ride-alongs (aka “road days”).

In the words of one controller, “The three days were just a vacation from work.”

Metro now has to respond

With the issuance of the WMSC audit, Metro has 45 days to respond by developing and proposing ways they can fix the issues identified.

Only time will tell if this time is different, but the WMSC seems optimistic. As opposed to the Tri-state Oversight Committee which oversaw Metrorail oversight for years, “the WMSC has additional powers and responsibilities to ensure steps are taken toward positive changes and that Metrorail understands the importance of maintaining those changes going forward.”

But as for improving the ROCC and fixing its deficiencies, the WMSC says, “It is up to Metrorail to actually implement the changes we require.“

Stephen Repetski is a Virginia native and has lived in the Fairfax area for over 20 years. He has a BS in Applied Networking and Systems Administration from Rochester Institute of Technology and works in Information Technology. Learning about, discussing, and analyzing transit (especially planes and trains) is a hobby he enjoys.