Thread by @MetrorailSafety

Today’s meeting includes an update on our ongoing audit and oversight work, votes on adoption of a number of final #WMATA safety event investigation reports & more
Watch live starting at 12:30 wmsc.gov/meetings/

We are proud to offer closed captioning to make this meeting more accessible. If you want the option to turn the captions on/off, please join us through Zoom.
Also join through Zoom webinar link here if you would like to participate with public comment wmsc.gov/meetings/

Join us on YouTube now for our public meeting on our #WMATA oversight work

WMSC Safety Officer Richard David has our safety message:

It’s National Preparedness Month.

Make a plan!

Consider who your plan is for, what your needs are, and shelter in place v. evacuation

The staff at the WMSC are passionate about everyone’s safety – so please always have a plan and stay safe.

Now on to public comments - none today (you can always reach out @MetrorailSafety here, on Facebook, Instagram, via email or through our web form wmsc.gov/report/)

Chair Christopher Hart opening remarks: Secretary-Treasurer Farrar-Dyke and the WMSC Finance & Operations Committee have successfully begun our first independent financial audit

CEO David Mayer: First, I would like to provide an update on our extensive work regarding the Rail Operations Control Center.

CEO Mayer: 2 weeks ago, we issued 21 findings as part of the ROCC Audit Report. The detailed, 50-page report clearly explains the safety concerns, how we identified them, and what Metrorail management is required to fix. wmsc.gov/oversight/audi…

CEO Mayer: To ensure that this audit was complete and accurate, we spent months interviewing Metrorail staff, reviewing documents and recordings, and conducting independent observations of the ROCC.

In an environment with a positive safety culture, everyone from frontline workers to the highest levels of management would feel able & obligated to raise safety concerns without fear of reprisal, and would be fully trained on & permitted to follow all procedures and checklists

Mayer: This is why it was so important to speak with so many of the Rail Traffic Controllers as part of this audit process, and to provide so much specific detail to WMATA so that the safety issues can be fully addressed.

CEO Mayer: Our interviews with 21 of 26 certified controllers employed as of March 1 showed a consistent picture, that was confirmed by reviews of audio recordings and through our separate safety event investigation work

CEO Mayer: To be sure that the controllers could speak freely, and that we minimized any operational impacts on Metrorail, we held these interviews in an off-site location at all hours of the day and night.

CEO Mayer: Given the sensitive nature of some of the concerns, we also ensured that a female WMSC staffer was one of our interviewers whenever we met with a female controller

CEO Mayer: We continue to engage with Metrorail to ensure that the corrective actions they will propose in coming weeks will fully address our ROCC Audit’s findings.

CEO Mayer: For months, the WMSC has directed revisions to Metrorail’s separate corrective action plans tied to our ROCC findings issued in December and May. Metrorail has now made substantive progress on these plans, and we have approved two for implementation.

CEO Mayer: One of the approved plans addresses proper, complete and recurring rail controller training on the use of emergency ventilation fans. The other addresses additional protections required to ensure third rail power is only restored when it is safe to do so.

Our work in those areas now shifts to monitoring implementation and assessing whether required steps are met in coming months. Even after plans are implemented, we will continue to monitor Metro’s adherence to these protocols to ensure that positive changes remain long-term

Mayer: The investigation into the July 7th derailment near the Silver Spring Station continues. Earlier this month, the WMSC participated in an after-action review hosted by WMATA that included Montgomery County Fire & Rescue.

Mayer: The WMSC is also resolving final aspects of other investigations, including of a June 6 smoke event near Capitol Heights. We are ensuring that all information relied on for the investigation is complete and accurate.

Mayer: Identifying and addressing safety concerns as part of a cycle of continuous improvement is a key aspect of the Safety Management Systems, or SMS, approach that Metro will incorporate into its new Public Transportation Agency Safety Plan.

Mayer: The WMSC has been working with WMATA to ensure that its “PTASP” is adopted and implemented with all required elements by the end of the year. Expects WMATA to approve PTASP in coming weeks, which would lead to WMSC Commissioner vote on approval in November

CEO Mayer: As far as the public health emergency, the WMSC remains focused on the safety of our staff, Metrorail riders, WMATA employees and contractors, and first responders.

We encourage all riders to wear face coverings when in the system, and at all other times you may come into close contact with others. This protects you and it protects others.

Mayer on reopening of all 91 stations earlier this month: WMSC has oversight for safety certification process. We reviewed Metrorail’s safety-critical issues list and completed other oversight work to ensure that hazards were addressed or mitigated prior to reopening.

Mayer: Safety certification is also required for projects like Silver Line Phase 2. Part 1 of our Pre-Revenue Service Review (construction) is underway. We’ve communicated with MWAA throughout the process, so that MWAA can adequately address all identified issues

Mayer: The second part of our Pre-Revenue Service Review will focus on Metrorail’s planning and preparedness to operate the line safely. Although Metrorail has not yet set a target date for opening, the WMSC continues to see adequate staffing and training as a key concern.

Mayer: Employees will need to be trained on their jobs, in addition to familiarization with the new territory. Training and familiarization is also required for everyone who will be working in the new Rail Yard near Dulles Airport.

Mayer: Regardless of Silver Line service levels, the WMSC remains concerned about ROCC staffing. A planned fourth operations desk would help with some workload issues, but requires significant staffing increases & an end to constant turnover we identified in ROCC Audit

Mayer: Staffing must be in place to operate the system in the safest possible manner.
The WMSC must concur with Metrorail’s safety and security verification report before the Silver Line extension can open to riders.

Safety event investigations are up next – we have one item on consent agenda, then four others to be presented.

Jemayne Walker, our track & structures expert, is presenting the first investigation report, regarding a serious contractor injury on May 1, 2020

Walker: The investigation shows that the contractor was standing on inappropriately constructed scaffolding in an enclosed portion of the pedestrian bridge where there were toxic fumes and dust.

Walker: The contractor was likely standing on a scaffolding support arm to reach a higher part of the wall for paint removal and grinding.

Walker: Several OSHA violations. WMATA did not confirm proper procedures and safeguards were in place for this work on Metrorail property. The scaffolding did not comply with multiple requirements. There were also no ventilation or exhaust controls in the enclosed area.

Second investigation report covers a collision/derailment in the Alexandria Yard on Feb. 10, 2020. Train struck hi-rail vehicle, wedging each 6-12 inches off the rails.

The Interlocking Operator responsible for vehicle movement in the yard was watching a movie trailer on an electronic device in the yard tower at the time of this event

Walker: That distraction likely contributed to the interlocking operator not effectively managing multiple responsibilities.

Walker: The hi-rail vehicle was being tested for approval to operate in the #WMATA system. There was no job safety briefing.

Walker: Hi-rail vehicle did not reach intended location. When the crew requested permission to return to grade crossing, they were told to stand by. Vehicle was partly over adjacent track.

Walker: A train entering the yard assumed the hi-rail unit was out of the way since the interlocking operator and a signal gave okay to proceed.

Walker: Lead car of train was moving about 10 mph when it struck the work unit

Walker: Damage included trucks, cable tray, cable tray bracket. Response also included not properly coordinating power removal.

Walker: Proper radio protocols not followed; action not taken to prevent collision. A lack of adequate supervision of Interlocking Operators within Metrorail contributed to this event, allowing for distractions like watching a movie trailer while on duty.

Metrorail conducted a safety stand-down for interlocking operators & tower supervisors. Topics included proper radio communications, policies barring use of computers and electronic devices in a way that could cause distraction, and procedures for movement of vehicles in yards

Walker: We at the WMSC have planned additional inspections of yard operations, partly in response to this event.

Next investigation is being presented by Program Specialist Adam Quigley

Quigley: Event on 2/14/20 where a train carrying passengers was routed into an area where third rail power had been taken down for safety reasons. The ROCC did not properly protect the area.

Power had been taken down because Train 909 struck a person at Minnesota Ave. The train operator and the person struck by that train were still on the roadway when the Rail Operations Control Center restored power to move the other train, Train 910.

When third rail power was restored, the trailing car of the train involved in the collision was in a position where it could have bridged the gap, re-energizing the area where the train operator and struck customer remained on the roadway, and an emergency response was underway.

Quigley: This event involved procedural non-compliance and emergency response deficiencies that put employees and customers at risk.

The investigation identified incorrect use of automatic signal routing and a lack of required radio announcements regarding the initial collision that could have prevented the operator of the misrouted train from entering the area where power had been taken down

Metrorail does not use any automatic, redundant protection features of the Advanced Information Management System to keep trains out of areas where power has been taken down.

The danger posed by this event highlights the need for independent confirmation that it is safe to restore third rail power. After the WMSC’s May finding, WMATA is putting an interim administrative oversight measure in place this month while a technical solution is developed.

The ROCC staff involved were not removed from service for post-incident testing as required. Metrorail only removed the operator of the train involved in the initial collision for drug and alcohol testing. The operator of train 910 was not removed

WMATA’s Safety Department was not aware of the train sent onto dead rail or the dangerous power restoration until the WMSC notified them of the facts we identified through our own, independent work. ROCC management did not include information about these aspects in their reports

Fire-Life Safety expert Richard David presenting the next investigation covering a 3/14/19 collision and evacuation

David: A customer who had been wandering the Ft. Totten Station for more than two hours used a platform end gate to access the Red Line roadway, and walked between the tracks toward Takoma (9:54pm)

David: About 24 minutes later, the customer was struck by an inbound train; The train operator left the cab to check on the person who was struck

David: The train operator did not make PA announcements to passengers on the train before entering the roadway

David: While the train operator was on the roadway, the operator saw passengers on the train had begun moving between cars using the end-doors.
When operator got back on the train, passengers said several other riders had self-evacuated through the side emergency door.

The Station Manager at Fort Totten was not notified about the collision until Metro Transit Police arrived at the station shortly after 10:30 p.m.

Based on station CCTV footage and MTPD information, 16 passengers self-evacuated. The first Metro Transit Police personnel on scene encountered two of those passengers on the roadway near the station platform at 10:33 p.m., approximately 15 minutes after the collision.

When Transit Police and the station manager became aware of those customers on the roadway, the ROCC was notified and the ROCC then de-energized power on Track 1, at 10:34 p.m. The remaining 14 passengers who had self-evacuated were still walking to the station platform.

59 more passengers remained on the train. MTPD eventually led them off the train onto the roadway to walk approximately 824 feet to the station. One person reported a minor injury during the evacuation.

There is no forward-facing train video of the evacuation because the train was keyed down and power was de-energized. Had the train been keyed back up, certain systems including the PA and video and data recording systems would have come back up.

David: This event highlights the importance of clear communication to customers, and the importance of vigilance on and around Metrorail property.

David: If customers, employees, or others had identified that this person was wandering the station for two hours, it is possible that the fatal collision could have been avoided. Metrorail could also consider additional measures, such as alarms or locks for platform end-gates.

David: If communication to passengers had been clearer, it is possible the self-evacuation could have been avoided.

David: Any type of evacuation creates risks for customers. Self-evacuation can pose additional hazards given unstable footing, the potential that some or all pieces of third rail could be energized, and the lack of any communication with other trains, work crews or the ROCC.

David: It is extremely important to provide customers with accurate information and updates so that evacuations only occur when necessary for life-safety reasons.

Next up is updates on WMSC’s past, present and future audit work; Chair Hart making some comments first

Hart: The safety issues identified in our ROCC Audit must be addressed expeditiously. Among other things, our audit revealed a toxic workplace environment at the ROCC that has resulted in low employee morale and high employee turnover, both of which are serious safety issues

Hart: A number of these safety concerns are similar to those identified in previous investigations by the NTSB & FTA. This includes some that are similar to those identified when I was the NTSB Chair during the investigation of the fatal 2015 smoke accident near L’Enfant Plaza

Hart: The Washington Metrorail Safety Commission has the responsibility, commitment and authority to require Metrorail to implement and maintain much needed safety improvements in the ROCC to help prevent future accidents

Hart: Our job is to provide an independent assessment of what must be done to improve safety. Metrorail’s job is to identify, develop and implement effective ways to get that done.

Hart: WMSC will evaluate WMATA’s Corrective Action Plan proposals to ensure that they do address the problems. Metrorail must implement and sustain the required changes. We will work with Metrorail every step of the way to ensure our mutual safety improvement goals are achieved

Hart: If all of those involved are on the same page and working collaboratively, rather than keeping their concerns and remedies siloed and tightly controlled, they will be more able to develop effective safety improvement ideas while avoiding potential unintended consequences.

Hart: That teamwork can even identify safety improvements that are also efficiency improvements – which will make the changes more sustainable.

COO Sharmila Samarasinghe with additional audit updates: #WMATA has a few more weeks to finish developing and proposing corrective action plans for each of the 21 ROCC Audit findings.

Samarasinghe: Our team is in regular communication with Metrorail, and we will ensure that any CAPs that we approve for implementation will address our findings when fully implemented. We will oversee that implementation, future closure and then conduct oversight checks

Samarasinghe: The WMSC has issued a total of 25 findings in connection with the ROCC over the last year. 4 findings December 2019-May 2020. 21 more two weeks ago in the ROCC Audit report.

Samarasinghe: Metro has submitted multiple revisions of proposed corrective action plans for Dec/May findings. WMSC will only approve these proposed CAPs for implementation when we determine they will produce the necessary changes that can be sustained long term.

WMSC has approved proposed corrective action plans on emergency ventilation fan training, and power restoration protections. Have directed additional revisions on CAPs for other Dec/May findings (dysfunction in the ROCC; uncoordinated remote console manipulation)

The WMSC issued two other audits earlier this year

RWP Audit (11 findings). WMATA proposed corrective action plans for these within required timeframe. WMSC approved/finalizing approval of most. Several others require a few more adjustments to fully address safety concerns identified. WMSC has directed Metrorail to make revisions

WMATA is making progress on earlier Track Maintenance & Training Audit. WMSC has closed CAP on uniform clear direction on heat ride inspections. WMSC has approved corrective action plans for the other findings, and WMATA is in the process of implementing those changes

Samarasinghe: Our next safety audit of WMATA’s elevated structures practices is currently underway. We have conducted a significant portion of our interviews and document reviews, and plan to complete our scheduled interviews within the next week or so.

Samarasinghe: We are just beginning the process for the audit that will follow – Metrorail’s Rail Maintenance Machines.
These are all vehicles that WMATA refers to as Class II vehicles – anything that rolls on the rails that is not a train that would carry riders.

Chair Hart says there are two resolutions on the agenda today, starting with improvements to the bylaws

Second resolution updates the FOIA policy to reflect the WMSC’s staffing and operations (previous policy was adopted before staff were hired and WMSC had experience of running our state safety oversight program)

That concludes today’s meeting. You can always reach out to us here, on Instagram instagram.com/metrorailsafet…, on Facebook facebook.com/MetrorailSafet…, through our website wmsc.gov/report/ or via email