Metro's history of failure: Part I

Introduction

This series of posts begins with a simple premise. Years of management failure at Metro have resulted in an unsafe system. The June 22, 2009 crash on the Red Line was but one consequence of a failed organization. Furthermore, unless fundamental changes are made within Metro, it is likely that more accidents will occur.

Pinning down all of the various causes is no easy task. Currently the NTSB is investigating the specific causes of the June 22 accident. A report will be issued in the future blaming the crash on a failed signaling system. Metro will likely spend a good amount of money developing a secondary train tracking system, and in some ways safety will improve. However, the bigger picture problems will remain. There will be future accidents. The cause will be different, but the reaction will be the same. It will have been a "freak occurrence" or something that no one could have prepared for. We will hear that regardless of the accident, the system is safe.

The system is not safe. It has not been safe for a long time, and without radical changes it will never be safe.

On July 6, 2009, the Washington Post published an editorial by Jim Hall, former director of the NTSB. He also went on the record in an interview with WTOP News. Hall believes that there is an indifference to passenger safety at Metro. "If you start with safety being job one," remarked Hall to WTOP, "then you figure the rest of it out. That's the message that's never gotten through to the local metropolitan transit system."

Hall identified a key problem at WMATA, the failure to maintain or encourage a culture of safety. The former head of the NTSB believes that WMATA prioritized cost savings and connivence over passenger safety. At the end of the day, Hall writes in the Post, "the agency probably viewed the chance of a severe accident as small enough to obviate the need for serious action."

Concerns Nothing New

Sound familiar? In 2005, former NTSB member Susan Coughlin discussed safety concerns with the Washington Post. Referring to the recent accident at Woodley Park, as well as a spat of derailments, she said "it's indicative of systematic oversight problems which, if left unaddressed, could produce a catastrophic accident"

The article in the Post, entitled "Safety Warnings Often Ignored at Metro" warned of an agency careening head-on towards disaster. The piece focused on several areas of safety concerns, including the lack of any meaningful oversight. Back in 2005, there were strong indications that safety concerns were being ignored. This was not just a matter of NTSB directives being ignored, this was a matter of safety questions by employees being ignored by managers and administrators. In one instance, this led to a derailment of a train at National Airport. There were no injuries, but over $100,000 worth of damage was done.

At the time, Metro General Manager Richard A. White said "what we have here is a head cold. We'll take our medicine and get better. But it's not like there's a body on the operating table hemorrhaging to death."

Rewinding even further, we go back to the 1996 accident at the Shady Grove station. During the Blizzard of 1996, a four car Red Line train overran the platform at Shady Grove and slammed into an unoccupied train. The operator of the train was killed. The immediate cause for the accident was identified as a failure of the computer braking system. The tracks were icy, and the computer system did not account for that when automatically applying the brakes. The failure, however, was much larger than simply a glitch with a computer.

In the NTSB's report, we read that WMATA had ignored the concerns of the train operator after his train overran the platform at Twinbrook. He was not permitted to operate his train in manual mode. Tracing it back even further, we see that Metro had ignored a growing trend of station overruns. Despite operator concerns, especially during inclement weather, WMATA still ordered operators to run in automatic mode.

In fact, back in 1996, the NTSB concluded that Metro "failed to fully understand the design features and limitations of the ATC system, which led to an unjustified management confidence that the system could ensure safe train operation under all operating conditions."

While Metro did learn that the ATC system was problematic in adverse weather conditions, it was never imagined that the system had multiple failure points. Just as Metro ignored station overruns and operator concerns before the 1996 crash, Metro had indications prior to the 2009 accident that there were problems with the signaling system.

To be continued. In the next part of the series, we will look at the signs Metro ignored prior to the June 22 crash, as well as the institutional factors behind this lack of focus on safety. In the third part, we will look harder at the ever-present budget problems that are the ever-present excuse for Metro's failings.