Safety Warnings Often Ignored at Metro
Responses to Derailments, Track Flaws and Station Overruns Have Fallen Short, Records Show

By Jo Becker and Lyndsey Layton
Washington Post Staff Writers
Monday, June 6, 2005

Second of four articles

On a clear and frigid night in January 2003, the last car of a Blue Line train jumped the tracks outside Reagan National Airport, smashed into the third rail and sheared an iron railing, sparks flying, before the 216-ton train shuddered to a stop on a bridge 30 feet above the ground.

The 46 passengers were evacuated without injury, but the derailment caused $100,000 in damage. And like most of the seven other derailments that followed in the next 20 months, it might have been prevented had Metro listened to warnings from its employees and safety officials, according to internal investigations.

Time and again, records show, the public transit agency has disregarded the advice of experts and failed to address safety issues. A Washington Post review of internal Metro documents, including accident investigations dating back eight years, found that:

· In a 20-month period ending in October, eight subway trains derailed -- twice as many as in the previous three years combined. Despite the increase, officials failed to put in place recommended safeguards.

· Metro is experiencing an increasing number of rail breaks, which can cause a train to leave its tracks, and inspectors missed the flaws that led to the breaks. Metro's auditors warned the agency that the department charged with inspecting the rails wasn't doing its job, but officials did little to address the problem.

· Trains are increasingly unable to stop where they should at station platforms, instead coming to rest inside darkened tunnels. The number of incidents grew from 104 in fiscal 1999 to 583 last year, despite warnings from two federal agencies to get the problem under control because it could be indicative of serious safety hazards.

Riding the subway is still far safer than getting behind the wheel of a car. Nationally, 14 people were killed and 42 injured last year in rail transit crashes or derailments, a figure that does not include suicides, federal government records show. Metro suffered no such fatalities in that time period. But the system accounted for nearly half of the nationwide injuries as a result of a November accident, when two trains crashed at the Woodley Park-Zoo/Adams Morgan Station.

The accident sent 20 passengers to the hospital with minor injuries. Experts said Metro was lucky that one of the two trains wasn't carrying passengers and that no one was killed. The crash was Metro's first in nearly nine years and is being investigated by the National Transportation Safety Board, which has found fault with the way Metro trains its operators.

Metro's recent performance is cause for concern, former safety board member Susan Coughlin said. "It's indicative of systematic oversight problems which, if left unaddressed, could produce a catastrophic accident," she said.

The safety of its nearly 660,000 daily passengers is Metro's most fundamental responsibility. But the agency is able to leave safety issues unaddressed without fear of formal sanction because no state, regional or federal regulators have direct power over it.

Although the federal government oversees air travel, Amtrak, ferries and other modes of mass transportation, it has no jurisdiction over subway safety. A regional safety panel, the Tri-State Oversight Committee, also has no regulatory authority.

Internally, Metro's safety department investigates accidents and develops policy recommendations to reduce risks. But it cannot require other departments to abide by its recommendations.

The agency also lacks accountability, records show; it rarely fires people who commit serious violations.

Industry officials say there is no fair way to compare the safety records of subway systems. The layout of the tracks, the technology that runs the trains and the weather all vary and can affect injury and fatality numbers.

Still, Metro Chief Executive Richard A. White said his is one of the safest systems in the country. In response to terrorism concerns, the agency installed sensors to detect chemical agents, put bomb-proof trash cans in the stations and has taken numerous other measures to protect the public.

To ensure that other safety hazards are more quickly addressed, White reorganized the agency in March and has since taken other steps. For the first time, for instance, Metro is setting deadlines for compliance with internal safety recommendations, and White said he will discipline managers who fail to meet them.

"What we have here is a head cold," he said of the agency's lagging response to expert advice. "We'll take our medicine and get better. But it's not like there's a body on the operating table hemorrhaging to death."

Derailments, Mistakes

After the derailment at National Airport, Metro's safety department appointed a team of investigators to find out what went wrong. Reconstructing an accident is akin to solving a whodunit: Investigators look at physical evidence, interview witnesses and branch out to determine the cause and assign responsibility.

At the airport, they found a trail of errors with plenty of blame to go around.

The track in question wasn't designed for daily use; it was a sharply curved "storage track" that agency protocol said should be used only to pull trains aside temporarily. But the department that controls rail traffic had pressed it into service two months earlier because the regular inbound track was closed for construction of a canopy on the platform.

Several managers had warned superiors that the track wasn't engineered to carry heavy, routine traffic. But officials ignored the warnings.

Track manager Larry Fuller, for instance, told investigators that "it didn't make me very happy" to learn that the track was still being used for that purpose "because I already told my boss it wasn't a good idea," according to the post-accident report. His superior, Doug Gibson, said he passed the warning up the chain: "We were not comfortable with the amount of traffic on the track," he told investigators, adding that Don Painter, then the head of the track department, was aware of the concern.

Painter, who has since moved to a new job, said in an interview that he didn't recall anyone expressing specific concerns.

After the derailment, Metro installed a restraining rail along the curve. The metal lip, which is attached to the rail, helps guide trains along sharp turns. But the agency has yet to install another one along a similarly tight bend at the West Falls Church-VT/UVA Station, despite an urgent order to do so in 2003 by Metro's board of directors.

Former deputy general manager James T. Gallagher, who left the agency in March, said it took time to secure the $277,000 needed to manufacture and install the safety device. "It ran into internal buzz saws," he said. "Sometimes even a deputy can't get lunch money."

Nationally, derailments are rare. San Francisco's smaller Bay Area Rapid Transit system, for instance, had three from 2003 through the beginning of this year, and none of the trains had passengers. Metro had eight over the same period, and two of the trains carried passengers, although no one was injured.

Many of the Metro derailments had a common factor: The track was not lubricated. Lubrication helps prevent derailments because the slick surface makes it difficult for train wheels to climb up the rail and pop off-track. As more trains derailed, records show, Metro safety officials repeatedly told the track department to lubricate tight curves.

But the department failed to consistently follow the advice. After a train derailed at the Alexandria rail yard in April 2003, Metro safety investigators concluded that the probable cause was the lack of a restraining rail along the curve and "no lubrication on the tracks." A Metro consultant later wrote that "lubrication alone would significantly decrease a risk of this type of derailment."

Painter said he immediately told workers to lubricate the area, which involves painting grease onto a portion of the rails with a brush, similar to basting a turkey. "I kept asking, 'Are you lubricating?' It got drilled into their heads," Painter said. But over time, the message was forgotten.

"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," Painter said.

A little more than seven months later, another train derailed along the same curve. Investigators cited dry track as a contributing factor.

Experts agree that safety instructions should not rely on word of mouth. But it wasn't until the end of April -- more than a year after safety officials first raised the issue -- that Metro put in place written standards that spell out where and when tracks should be lubricated.

Inspection Problems

The constant force of heavy trains batters subway rails, causing wear and tear. To catch weaknesses that could cause derailments, Metro employs 31 "track walkers." Their inspections cover the 106-mile system twice a week as they hike the tracks in search of flaws.

The agency also hires a contractor to drive ultrasonic machinery over the rails, getting a sonogram-like glimpse inside the steel, where defects that can turn into breaks may first develop.

"What you want to find is potential problems," said Steven A. Feil, chief operating officer for rail. "Breaks are after the fact."

The number of major rail breaks during normal operating hours has increased from two in 2002 to eight last year, records show. Flaws that led to the breaks were not picked up by ultrasound or routine track inspections.

Records point to chronic shortcomings in the agency's track inspection program. Metro didn't formally train its track walkers until 1999. Internal audits in 2000 and 2004 found that track walkers were not adequately trained. Some walkers didn't know to report "unsafe conditions," and even experienced walkers sometimes missed problems because the eight miles they must cover each day was too great, the 2004 audit found.

"If I were an outside person looking at that audit, I would read it and say, 'Oh boy, there are some real problems here,' " Painter acknowledged. "But every time we've had any type of audit, we did everything within our capability to take that as good feedback and see what we could do better."

Metro officials were jolted to a new awareness Nov. 29, when rush hour traffic on the busy Red Line screeched to a halt. A highly unusual 65-inch break had severed a rail at the Judiciary Square Station. In many cases, Metro's "broken rail protection" system will cause a train to lose power before it hits a breach in the rail. But the system wasn't designed to pick up the type of break at Judiciary Square, and several trains bumped over it before it was discovered. Had the break been along a curve, safety chief Fred Goodine said, those trains likely would have derailed.

An earlier ultrasound of the area had pointed to a potential flaw, but the private company that conducted the test had mistakenly concluded that there was no problem and had moved on without informing Metro, agency officials said. Those officials criticized the company and began sending a Metro employee along with the contractors to supervise the work.

Early this year, a panel of officials from other subway systems brought in to study Metro's problems also targeted the track department, saying that track walkers were poorly trained and apathetic.

Metro officials said they are now conducting more ultrasonic inspections and improving training. They hope to strengthen the department by adding 14 track walkers next year. "We're not perfect," said Lou Testa, who took over the department from Painter on an interim basis. "But we're trying."

Lack of Regulation

The Federal Transit Administration, which provides funding for public transit agencies, conducts audits but has no authority to dictate even basic safety rules, such as the number of hours train operators must rest between shifts.

In contrast, the Federal Aviation Administration can enforce regulations covering the manufacturing, maintenance and operation of aircraft. Unlike the FTA, it can force airlines to address problems flagged by accident investigators from the National Transportation Safety Board.

Prompted by several fatal subway accidents, the NTSB pushed for federal oversight, but Congress passed a compromise law that instead required the creation of state boards by 1997 to monitor subway safety. Most of those boards do not have the resources or authority to enforce safety standards, however.

The board that oversees Metro is no exception. The Tri-State Oversight Committee, consisting of transportation and emergency management employees from Virginia, Maryland and the District, has no office and no support staff.

The committee can't dictate safety rules or levy fines. The FTA criticized it in 2000 for lacking the resources to adequately oversee rail safety. Before the three jurisdictions raised a total of $150,000 to hire a consultant last year, the committee operated without any source of funding.

California, in contrast, allocates $2.3 million a year to oversee two subway systems and two commuter railroads. One of the few states with a muscular monitoring program, it has a team of expert inspectors, can fine transit systems that violate safety standards and can veto car or track designs.

"You can wait until an accident happens and try to fix problems, or you can be proactive and try to prevent accidents by having a highly skilled third party taking a look at issues from design through daily operations," said Richard Clark, who oversees rail safety for California.

Inside Metro, the safety department also wields little power. White brought Goodine to the agency in 1997 to set up an aggressive safety program. But Goodine said his biggest challenge has been persuading what he calls Metro's "frozen middle" to address issues that can endanger passengers.

"There needs to be more urgency and accountability," he said.

Goodine can warn the bus department, as he recently did, that its operators aren't consistently inspecting their vehicles before heading out for a shift, as required by law. But it's up to the bus department to force operators to do it. When the track department failed to lubricate tracks, Goodine had no authority to order workers to do so.

"What we lack," White acknowledged, "is a clear intervention process."

White said a recent agency-wide reorganization will help address that problem, but one of his changes is being met with mixed reviews. Some worry that the safety department's profile will drop further because Goodine no longer reports directly to White; he reports to Metro's auditor general, a move meant to consolidate the agency's investigative functions.

"We're concerned that critical safety matters may not be brought to the attention of the chief executive in a timely and unfettered way," said John Contestabile, a member of the Tri-State Oversight Committee.

Federal Warnings Ignored

After a 1996 crash in which a Metro train operator was killed at the Shady Grove Station, federal safety investigators delved into Metro's operations and found a troubling trend: Hundreds of trains a year were shooting past station platforms.

Although operators can manually brake a train, Metro mostly relies on an onboard computer system for routine stops. If the computer misses a signal from coil markers embedded along the track, the train enters the station too fast. It overruns the station and comes to rest with some cars inside the tunnel. Passengers often can't get off and must ride ahead to the next station and catch a train back.

Because Metro has a separate computer system that stops a train before it can crash into another, officials do not consider station overruns a safety concern. But both the National Transportation Safety Board and the Federal Transit Administration said in separate reports that Metro should pay more attention to overruns.

"All station overruns are serious and should be investigated" because operators rely so heavily on the automatic equipment, the FTA wrote in a 1997 report. Overruns could also signal a safety issue, such as a braking problem.

But unlike most rail agencies, the FTA said in the report, Metro had done little to get to the bottom of the problem. The agency failed to check whether the overruns were random or whether there was a pattern determined by weather, location or the type of rail cars, the report said.

Had Metro undertaken such an analysis, the FTA said, it would have seen that a significant number of overruns were occurring in wet and icy weather -- the type of conditions that the operator in the Shady Grove crash was facing as his train failed to brake in automatic mode. As it turned out, Metro was not properly setting its brake pressure to consistently stop computer-controlled trains on wet tracks. It also was ordering operators to use the automatic mode regardless of the weather.

In 2002, Metro officials assured NTSB investigators that they had purchased equipment that would fix the problem, records show. But it has worsened. In 1996, the year of the Shady Grove accident, Metro had 322 overruns, agency statistics show. Last year, trains missed their stations 583 times, records show. San Francisco's system, which Metro officials say has superior technology, had 37 overruns last year.

Metro's overrun problem is "something that needs to be looked at very, very carefully and quickly," said Brian Cudahy, a subway expert and former FTA official.

Metro officials stressed that the number of overruns is minuscule when compared with the 11 million station stops made last year. Nevertheless, in January, White told Assistant General Manager P. Takis Salpeas to get to the bottom of the problem quickly because the agency was under pressure from NTSB and other fronts. Salpeas said he hopes he has found the answer: installing an electronic backup system on the trains.

Metro must get the problem under control so it can go forward with plans to run eight-car trains to ease crowding, Salpeas said. Because eight-car trains are 600 feet long -- the same length as the platform -- there is no room for error.

While station overruns and rail breaks draw little public attention, November's high-profile crash at the Woodley Park Station unnerved many daily riders. The crash occurred when an out-of-service train rolled backward and hit an idling, occupied train at about 30 miles an hour.

After the accident, the NTSB issued an unusual emergency directive to Metro that criticized the agency for not adequately training its operators.

Metro officials "did not anticipate a situation in which an uncontrolled rollback could occur," the NTSB wrote. Consequently, operators were never trained to manage "an event similar to the one that occurred."

After the 1996 Shady Grove accident, the NTSB warned Metro that its cars were susceptible to "telescoping" -- when a crash causes rail cars to fold like a collapsible telescope -- and urged Metro to strengthen the cars. Metro said it would buy stronger cars in the future but decided any benefit of retrofitting its fleet was outweighed by the huge cost.

At Woodley Park, some of the cars in the runaway train telescoped. Had the cars been full, experts said, passengers likely would have been killed.

Few Get Fired

After investigating the Woodley Park crash, Metro officials laid the blame on the novice train operator. The agency fired Lamont Lewis, accusing him of "gross violation of basic operations procedures."

It was a rare move at Metro, where employees seldom face stiff punishment, records show. This is true even for workers who put passengers in jeopardy.

Last year, Metro statistics show, bus and train operators committed 737 serious safety violations, such as a failure to pay attention to traffic control signals or opening the doors on the wrong side of the train. In more than half of the incidents, operators received a reprimand or lighter punishment. Fourteen, or less than 2 percent, were fired.

To some extent, Metro management is hamstrung by the protections afforded to unionized workers. In February 2004, for instance, a bus driver hit a pedestrian in the District. Metro recommended that the bus operator be fired. But the union appealed, and an arbitrator ruled that the operator could return to work.

Management also metes out discipline inconsistently, a review of accident records and personnel decisions show.

In 2001, Metro tried to fire a driver who lost control of his bus and hit two trees in a Pentagon parking lot. But two bus drivers who caused injuries to people that year were reassigned to desirable jobs after their accidents. One of those drivers fell asleep at the wheel and hit a pole, sending six passengers to the hospital. Metro switched that driver's job, making her a subway station manager.

The other driver hit pedestrian Patricia Ann Skinner, a 35-year-old editor at a newsletter publishing company. The driver had seen Skinner, honked the horn repeatedly and waved her arms -- but never applied the brakes, according to the accident investigation. Skinner's life changed forever that day; she lost a leg from the hip down. Metro paid her millions in an undisclosed settlement. The driver became a subway station manager.

Jack Requa, who heads Metro's bus department, called those decisions "mistakes."

"We don't do that anymore," he added.

White said one goal of his reorganization is to make personnel decisions more consistent by giving the human resources department the authority to review disciplinary actions.

"It's a new day around here," he said. "We slid into a comfortable period. Now we're going through the turbulence, and my job is to make sure that the rest of this organization is as shook up as I am."

But the agency continues to forge ahead with a pilot program, introduced last year, called "alternative discipline." Instead of suspending and docking the pay of unionized workers who violate safety rules, managers now routinely put a letter in their files and allow the workers to stay on the job.

The agency estimates that the new policy saved $700,000 last year by reducing the overtime costs of replacing suspended workers. The program also has improved labor relations, said R. Richard Froelke, Metro's chief labor negotiator. "Do you want to club employees over the head," he asked, or treat them "with dignity and respect?"

Jackie Rhodes Jeter, spokeswoman for Metro's largest union, said the program has done nothing to improve morale. Boston's Massachusetts Bay Transportation Authority, the only other transit agency in the country to try the program, dumped it after a year, concluding that it did nothing to correct unsafe behavior.

Goodine, Metro's safety chief, said he worries that lax penalties for serious safety violations lead to lax behavior.

"If you don't get a ticket for going through a stop sign, it probably won't change your driving behavior much," he said. "But if you get hit with a $200 fine, you'll think twice."

Database editor Derek Willis contributed to this report.

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