“Metro internal review of Dec 10 Red Line incident finds safety hazard resulted from human error, insufficient training”

From WMATA:

“Metro’s post-incident review of the December 10 Red Line disruption has identified two violations of safety policies or procedures–prompting immediate corrective action–as well as specific areas where additional training and supervisory oversight is required.

The review, led by Metro Chief Safety Officer Theresa Impastato, found that the ROCC controller did not follow safety procedures upon receiving a report of “light sparks” in the tunnel outside Tenleytown Station. While the train operator did not explicitly report “smoke” or “fire,” the ROCC controller appropriately recognized a potential hazard and requested that the following train (Train #130) conduct a track inspection but failed to instruct Train 130 to offload its passengers before beginning the inspection. The controller’s actions violated Metro’s safety rules and procedures for smoke/fire incidents, and immediate corrective action is underway.

The review also found that, after departing Friendship Heights and entering the tunnel, Train 130’s operator notified ROCC that she had properly stopped the train in advance of a small fire on the track ahead. The ROCC controller directed the train operator to return to Friendship Heights, a process that required deactivating the train’s anti-collision protection system in order to move against the normal direction of traffic. ROCC also instructed the operator to perform a specific procedure to turn off the train’s ventilation systems. The train operator did not properly execute these procedures, and subsequently could not proceed faster than 2-3 mph, resulting in an unacceptable delay in returning passengers to the station.

After the incident, Metro technicians inspected the train and did not find any contributing mechanical problems. The review subsequently determined that, while attempting to turn off ventilation systems and override the automatic train protection system, the operator toggled the wrong circuit breakers, an error that engaged the brakes and turned off the lights.

ROCC made several attempts to assist the operator during the incident by verifying the necessary steps over the radio. However, the troubleshooting effort was deemed insufficient by the review and will be improved. Further, the review concluded that operators need better training on rarely used mechanical procedures, and will recommend new training to execute the procedures during a simulated tunnel emergency.

ROCC reported the incident by phone to DC’s 911 center (DC Office of Unified Communication), and the fire department responded to Friendship Heights Station. While Metro’s review into emergency response notification is ongoing, process changes are anticipated.

Finally, the review found a safety violation and identified critical errors by ROCC and Emergency Response Team members in the tunnel related to the restoration of third-rail power. Protocols to protect workers from electrical injury were not followed in this incident, and appropriate corrective action was immediately undertaken as a result, including administrative processes, increased supervision, and reinforcement of policies.

Metro’s policies regarding fire/smoke incidents have been reinforced with all ROCC controllers and supervisors, and SAFE has increased supervisory oversight of ROCC staff to ensure compliance with operating procedures. In addition, train operators are being refreshed on procedures from this incident and related troubleshooting. Additional action is planned to improve training and emergency response times.”