There are no safeguards against investigation interference at Metro’s ROCC, a report finds

Metro protocols don’t ensure investigations that occur are fully independent from the employees involved, according to a report recently released from the Washington Metrorail Safety Commission (WMSC). Internal Metro investigations don’t always rely on first-hand reports from staff directly involved in the incidents, but instead descriptions of the events passed up through management ranks which could be altered.

This is the fifth and final part of a series diving into issues at the Metrorail Rail Operations Control Center (ROCC) identified by the Washington Metrorail Safety Commission. The introduction can be found here.

Without protocols to ensure investigations are independent, the WMSC is concerned that those that might be involved in incidents aren’t completely excluded from the investigation process itself.

The commission discovered during its latest audit that, “ROCC managers had attempted to shape statements [rail controllers] provided as part of investigations.”

In addition, the WMSC noted there aren’t audio recordings of all desk positions inside the ROCC, including the fire liaison and ROCC assistant superintendent. Additional microphones, and recordings of the cordless phone used by ROCC assistant superintendents, will be required to be installed.

While investigations that involve ROCC staff aren’t independent, it’s not clear that all incidents which might require investigations are reported. The WMSC highlighted a “deficient reporting culture” in which front-line staff at the ROCC no longer think it’s useful to report issues.

One issue that’s gone unfixed for years is that of speed readouts, the electrical signals that trains pick up to know how fast they’re allowed to go. Controllers told the WMSC of 17 locations across all six rail lines where speed readouts regularly drop. Controllers said that “…there is no purpose to continuing to report the problems over and over again” when they never get fixed.

Speed readouts, one of the focuses of a prior WMSC report, are also needed by Automatic Train Operation in order to work properly. Without working readouts, operators have to perform manual actions in order to get their train moving again.

Controllers, train operators, maintenance technicians, and others run the risk of becoming complacent and, like in the case of an October 20, 2019 collision, begin to ignore safety steps which can have serious consequences.

To fix reporting issues the WMSC is requiring that Metro obtain source “data, statements, and other relevant information” as part of each safety investigation, rather than relying on managers and others to collate it for them. Adding recording devices to the untracked phones in the ROCC is another requirement.

Emergency communication breakdowns

Breakdowns in communication between Metro and the DC Fire and Emergency Medical Services Department during the fatal L’Enfant Plaza smoke incident led to a fire liaison position being added into the ROCC. The liaison position, staffed by active-duty fire department personnel, would serve as a conduit between the ROCC and local fire departments to help the two communicate better and in a more seamless fashion.

But it turns out that few inside the ROCC actually know what the fire liaison’s position is and what the person filling it is supposed to do, as well as how they’re supposed to work with ROCC staff.

“There is no consistent, clear, concise, immediate and reliable Metrorail communication process for safety-critical information between Metrorail personnel and the fire liaison,” says the WMSC report.

Single points of failure exist in the ROCC that can hamper communication between groups - for instance, the ROCC assistant superintendent who may leave their desk to monitor an active incident rather than be available to be a “dispatcher” for information.

It also turns out that during the Covid-19 pandemic, between March 2020 and July 2020, Metro used personnel from within the agency to staff the fire liaison desk who weren’t trained for it, “[were] unfamiliar with incident command,” didn’t use checklists, and were “unfamiliar with relevant standard operating procedures.”

Use of an untrained employee, as well as Metro’s use of its backup rail control facility, contributed to confusion during the July 7, 2020 derailment at Silver Spring. “Without proper training and significant fire rescue department experience for the fire liaison,” the WMSC says, “that critical emergency response coordination will break down.“

During the July 2020 derailment, the ROCC controllers were operating out of the backup rail control facility. A cell phone used by the fire liaison position to communicate with regional fire departments wasn’t available there - only at the primary location, so the fire liaison wasn’t able to easily talk with the local responding jurisdiction.

Other incidents with fire/rescue responses that were impacted by breakdowns in communication include the December 10, 2019 fire outside Tenleytown and a report of smoke at the Capitol Heights station on June 6, 2020.

Procedures that Metro has in place are also potentially dangerous, according to the WMSC. Audio that commission staff reviewed during an investigation into the June 6 incident revealed that when the station manager reported a smell of smoke, they were questioned “multiple times” by the ROCC controller “whether it may not be smoke, but rather brake dust.” This back-and-forth led to a delay in calling the local fire department and an evacuation of the rail station.

Rectifying these emergency communications issues will require Metro to clarify the position of the fire liaison’s role, make it easier for real-time updates to be sent inside the ROCC and to those higher up, update or rewrite procedures, and ensure minimum training standards.

WMSC’s next public meeting is today (Tuesday). Clck here for more information.