Follow along with this series over at Greater Greater Washington.
Previously, we looked at a rash of accidents involving Metro track workers. A common theme across many of those incidents was a problem with the implementation of safety rules within Metro.In some cases, had rules been followed, the accidents would not have occurred. In other instances, implementation of NTSB recommendations might have averted tragedy. A similar theme emerges upon a close examination of Metro's recent history of derailments. For the purposes of this post, we will focus on the past 6 years of derailments. The fatal 1982 Orange Line derailment will be addressed in a later installment.
Since 2003, Metro has experienced a significant number of derailments. Many of these incidents involved out-of-service trains in rail yards, or on segments of pocket tracks. There are several notable incidents in recent history that have involved in-service trains, including one that resulted in passenger injuries. The causes of these derailments vary, though one factor remains the same--a failure to implement safety improvements throughout the system.
On January 20, 2003 the last car of a Blue Line train derailed along the elevated track outside of the National Airport station. Forty-six passengers were safety evacuated on that frigid night, though the damage totaled over $100,000. Over the next five years, there would be at least nine more derailments. In June of 2005, amid the rash of derailments, the Washington Post published an investigative piece entitled "Safety Warnings Often Ignored at Metro." The feature piece pours over internal Metro documents, as well as accident reports, and comes to some startling conclusions. Many of these were eerily prescient. After the National Airport crash, an internal investigation determined that employees were aware of the potential for problems. Documents showed that track managers expressed concerns relating to the type and condition of the track being used at the location. According to interviews, those concerns were passed up the chain to upper management, though no action was taken.
Warnings about other causes of derailments, such as a lack of track lubrication were also ignored. Investigators determined a lack of lubrication caused a derailment at the Alexandria rail yard. There was a brief push towards getting track properly lubricated, but over time the efforts began to falter. Don Painter, former manager of the track department, told the Post that he blamed a lack of institutional memory. "The superintendent retired, the assistant superintendent went to a different location, the maintenance manager went somewhere else, and the guys, when no one told them they needed to keep lubricating, the ball got dropped."
It took a year and several derailments later for Metro to implement directives regarding track lubrication.
Metro's track department was rife with systemic problems, especially concerning track inspections. The Post's investigation turned up a 2004 audit that showed some track workers did not know how to report problems to their superiors, and that inspectors often overlooked problems because they were required to cover an unrealistic amount of track each day. Additionally, prior to 1999 there was no official training program for track walkers, and audits showed that even after programs were implemented there was a lack of proper training.
Nearly four years after the Blue Line derailment, and 18 months after the Post article, a Green Line train derailed outside of the Mt. Vernon Square station. At 3:45 pm on January 7, 2007, the fifth car of the six-car train derailed, injuring 23 people. The NTSB determined that a problem with wheel maintenance caused the derailment. In the Railroad Accident Report, the NTSB also identified systemic problems within Metrorail. From the the report, RAR-07-03,
WMATA was aware of the wheel climb derailment problem with the 5000-series cars before this accident. Transit industry research and discussions with WMATA management indicate WMATA was aware of work done by the Transportation Research Board for the National Academy of Science and National Academy of Engineering on flange climb derailments in transit operations. Additionally, WMATA commissioned, participated in, and received the final Wheel-Rail Interface Study from the TTCI. Extensive testing to determine the cause of these relatively similar derailments in the 5000-series cars failed to produce a solid answer. Also, the APTA panel concluded that there was no single cause in the seven derailments it examined; however, the panel did identify several specific factors and made recommendations for WMATA to consider to prevent future derailments. Nonetheless, after requesting reviews by industry experts and funding related research work, WMATA failed to effectively address the proposed safety recommendations before this accident. The Safety Board therefore believes that WMATA should establish a process, including a single point of responsibility, to prompt timely evaluation and action on proposed safety improvements that are identified as a result of accident and derailment investigations and related research projects.In June 2008, an Orange Line train derailed outside of the Courthouse Metro station. There were no injuries, but over 400 passengers needed to be rescued from the tunnel. Significant damage was done to the track in the area. Interestingly, the train operator did not immediately realize the derailment had occurred. A Metro supervisor happened to be riding on the train, felt a jolt, and alerted the train operator. The train had traveled more than 2,300 feet with the front wheels of the third car off the track.
An internal Metro investigation determined that a track walker had failed to report a significant problem with the track in the area. From a WMATA statement:
"Our inspector failed to recognize the out-of-tolerance rail conditions," according to Metro's Chief Safety Officer Ronald Keele. "The track conditions compounded with the forces of the moving train caused one wheel to climb atop one track and the other wheel to drop to the ground. We are very fortunate that there were no injuries."The inspector was suspended for five days as it was his first offense. Again, Metro stated they would work to revamp their training for track inspectors.
The findings of Metro's internal investigation determined that the track inspector failed to detect "defects in the track's geometry" in the area of the derailment and "violated several inspection procedures," according to Keele.
The inspector did not inform the Operations Control Center of dangerous track conditions, did not report any dangerous or defective conditions to his supervisor, and failed to properly measure the space between the two tracks.
Metro's safety record regarding derailments highlights significant organizational deficiencies. Time and again, there was prior warning that problems could develop. Time and again, these warnings went unheeded. The same pattern emerges when looking at prior collisions and "near-misses" on Metro. Again, we see warnings from both within Metro and the NTSB that were ignored. It was no secret that trouble was brewing.