Near miss on Metro in March

The Washington Post reported yesterday about another incident where the automatic train protection system failed. On March 2, 2009 a Vienna-bound Orange Line train overran the platform at the Potomac Avenue station. The train operator activated the "mushroom," or emergency brake, and stopped the train one car-length beyond the platform. The train was off-loaded and taken out of service.

Platform overruns do happen, and can be indicative of braking problems, but are generally not considered an urgent safety problem. In this case, however, the train had entered a block of track that was occupied, and stopped only 500 feet behind the leading train.

Metro did not make the March 2 incident public, and according to the Post, did not disclose it to the NTSB during their investigation of the June 22 crash. The NTSB learned of the incident through the Tri-State Oversight Committee, the generally tooth-less organization that monitors Metro.

The general consensus is that the March 2 incident foreshadowed that a train could enter a block of track occupied by another train. The near-miss was yet another reminder (like the near-miss between Foggy Bottom and Rosslyn) that the automatic train protection system was flawed. In the specific case of March 2, Metro insists this was due to a failure on the train, and not in the track circuit. This, Metro believes, absolves them of all responsibility because it is "totally different" than the June 22 crash. Safety experts disagree, however, stating that this incident is alarming in that it shows that the system is not fail-safe.

The Tri-State Oversight Committee also states that on June 3, they received a complaint from a Metro employee that the ATP system was unreliable.

The TOC demanded Metro investigate the March 2 incident, however they have not yet received an official response. Metro spokeswoman Lisa Farbstein was also unaware of the incident until she was asked by the Post.

What does this all mean?

Yet again we see an amazing display of arrogance by Metro management. John Catoe, who has promised increased transparency, yet again failed to disclose an incident to either the public or the NTSB. Metro officials, who have again and again dropped the ball on safety issues, made the determination on their own that a failure of the ATP system was irrelevant to the fatal June 22 accident. If Metro is serious about improving safety, they must disclose any and all incidents that could in any way be related to the June 22 crash. Any incident involving the ATP system must be discussed with the NTSB. It is not up to Metro to decide what is and what is not relevant to the investigation.

As this story unfolds, it becomes alarmingly clear that Metro was aware that there were problems with the ATP system. Metro knew that there were multiple failure points, be it failed equipment on a train, "flickering circuits" or failed communications cables. These failure points resulted in trains being in the dark about their location relative to other trains. On more than one occasion, a failure of the ATP system resulted in operators using the emergency brake to prevent a disaster. Yet it was not until 9 people were killed on June 22 that Metro acknowledged problems with the system, and that was only after the NTSB and the media took them to task.

This is unacceptable. John Catoe, as well as any other top management relating to safety, must be fired. The Metro Board must take action, and Jim Graham especially must decide if it's worth continuing to defend Catoe. The management at Metro could not see the writing on the wall, that it was simply a matter of time before a crash of catastrophic proportions occurred. The people whose jobs are dedicated to ensuring the system is safe failed. Metro was lucky that the failure happened when and were it did. It is by the grace of god and good fortune we are not discussing an incident that resulted in hundreds of deaths and the system being shut down for months.

Fire John Catoe. Fire his deputies and his safety chief. Search the nation for people who have expertise in managing complex organizations that must be safe. Jim Graham is the head of the WMATA board. He is also seeking re-election to the DC Council next year. I might be just one blog but I'll make sure this hangs around his neck for the duration of his campaign.

This is absolutely ridiculous. How many more times do we need to hear about an undisclosed "near miss" before we realize that Metro failed in a spectacular way. In most other countries, there would have been a criminal investigation opened by now.

UPDATE: The WaPo is now reporting that the NTSB was "verbally" notified by a Metro employee of the March incident. Metro, however, did not provide any further information in the days following the June 22 crash.