Errors Are Found In Metro Accident
NTSB Probes Track Deaths

By Lena H. Sun
Washington Post Staff Writer
Friday, October 26, 2007

The operator of the Yellow Line train that struck and killed two Metro track workers in Alexandria almost a year ago failed to follow proper procedure while operating the train, and lied to federal investigators about being on her cellphone and when she hit the emergency brake, according to reports and interview transcripts released yesterday by the National Transportation Safety Board.

Two track inspectors, Leslie A. Cherry and Matthew Brooks, were working along the track near the Eisenhower Avenue Metro station when they were struck Nov. 30 by an empty train. Cherry died that day; Brooks died Dec. 7.

The NTSB report describes the basic facts of its investigation, which included participation by Metro. The report does not, however, make conclusions about what caused the accident or suggest safety recommendations. The board is to determine probable cause and make recommendations after a hearing.

Metro General Manager John B. Catoe Jr., who took over the top job two months after the accident, launched an aggressive systemwide safety improvement program this year to increase accountability, change the culture of the organization, and reduce bus and rail accidents by at least 50 percent.

Metro ordered changes in procedures after the accident.

"We've enacted many steps to avoid that kind of tragedy and to make our system as safe as possible," Catoe said.

According to the report, the train operator and track workers failed to follow proper procedure. At the same time, there were not enough procedures in place to ensure that personnel in the Operations Control Center, which handles all train movements, were communicating regularly with track inspectors in the field.

The train operator was leaving the Huntington Avenue station and heading toward the Eisenhower station before the accident. In violation of Metro procedure, she did not request permission from the control center to be on the main tracks, the report says.

She also told investigators that a personal cellphone was not used while she was operating the train. Cellphone records show that a 50-second call was received on her personal phone shortly before the 9:30 a.m. accident, the NTSB report said. Metro policy prohibits operations personnel from using personal cellphones while on duty.

Investigators said she sounded her horn twice. After she blew the horn the first time, from about 698 feet away, 15 seconds before impact, one track worker gave a variation of a "move forward" hand signal, she told investigators. Metro rules require track workers to move their hand, flag or a light in an up-down motion before a train is allowed to proceed. If appropriate acknowledgment of the horn signal is not received, "the vehicle shall be brought to an immediate stop," according to Metro's rules and procedures handbook. Train operators are supposed to use an emergency stop button any time a train must be stopped to prevent a collision.

Instead, the train continued forward, and at 241 feet from the track-workers' position, about four seconds before the accident, the train operator again sounded her horn. The operator said that the workers were clear of the track and that as the train moved past them, "the train operator heard the train strike the track-walkers."

The operator, identified in NTSB documents as Lynette Harris, has since been banned from operating a train or bus for Metro. She has been a Metro employee since 1999 and a train operator since 2001. Harris, now on workers' compensation, could not be located for comment.

In two interviews with investigators, Harris said she hit the emergency stop button, known as a "mushroom." In one interview, Harris was asked what her understanding of the rules were when approaching track-walkers. "You're supposed to blow your horn," she said, according to the transcript. Asked what she would be required to do if the workers were on the track, in harm's way, in front of the operator, she responded: "Stop the train immediately, mushroom and blow the horn." According to the NTSB report, "the mushroom was not depressed until about 14 minutes after the train was stopped."

The new rail procedures include limiting track inspectors to rail checks from 10 a.m. to 3 p.m., when fewer trains are on the tracks. A directive in April ordered track inspectors to contact the control center by radio after they leave a station or pass an interlocking, the part of the railroad where tracks can cross each other. The control center, in turn, must repeat back to the inspector to confirm accuracy and to inform train operators in the area, until personnel clear the work zone.

According to the NTSB, the control center had not been required to advise the track inspectors killed in the Alexandria accident that a train was moving toward them. Train operators who have been notified that employees are on the track must put their trains in manual mode, instead of automatic, two stations before arriving at the work site and must travel no faster than 35 mph.

Although the operator sounded her horn twice, video from an Eisenhower station platform camera showed that the lead track-worker "showed no reaction to the train" just before the accident. Metro officials said it was possible that the workers, who were on one track, thought the train was on the opposite track and might have assumed they were safe. The NTSB said the two workers were on the northbound track, between Huntington and Eisenhower stations. The empty train would normally have been on the opposite southbound track. But because a piece of the southbound track was out of service, the train was routed against traffic on the northbound track.

During routine drug and alcohol tests for the train operator, supervisor and personnel in the control center, a control-center trainee tested positive for cocaine, the NTSB said. Metro spokeswoman Lisa Farbstein said the employee, whom she declined to identify, was employed from May 1999 to May 2007. "The controller trainee did not play any direct role in the incident," Farbstein said.

Staff researcher Meg Smith contributed to this report.