Safety Procedures Not Followed, NTSB Says
Thursday, January 24, 2008
Three Metro employees were struck and killed by Metrorail trains in two accidents in 2006 because the employees and a train operator failed to follow proper safety procedures, the National Transportation Safety Board concluded yesterday.
The board also found that transit agency rules and procedures lacked adequate safeguards to protect track personnel; ensure that train operators were aware of track work being performed; and provide that trains operate at reduced speeds through work areas.
At the time of the accidents, the Operations Control Center, which controls train movement, made one announcement informing train operators that employees were working on the tracks. After one accident, in November, Metro required control center workers to make announcements every 20 minutes to inform train operators where maintenance work was being done.
The safety board made several recommendations, including having surprise safety inspections and requiring that pre-work briefings take place to ensure that track workers know their duties and the locations of safe areas.
The board also recommended that Metro "promptly implement" new technology that automatically alerts track workers of approaching trains and train operators of workers on or near the tracks. Such systems are being tested in the Boston and Baltimore subways.
Although Metro changed many of its policies after the 2006 accidents, safety board members said it was imperative for the system, the nation's second busiest after New York's, to have a "strong safety culture" so that employees follow the rules. "A strong safety culture doesn't take dollars; it takes a will," board member Debbie Hersman said. "They had rules. Those rules weren't observed."
Family members of the track workers attended yesterday's hearing and faulted the agency for taking so long to make changes.
Betty Waldron's husband, Michael, died when he was hit by a Metro train near the Braddock Road Station in October 2005. "I wish it had happened before my husband was taken from me," she said.
Sophia Cherry's husband, Leslie, was one of two employees fatally injured in November 2006. He did not know that trains were sharing a track that day and had complained in the past about not being adequately informed about single-tracking. "Had he known, he could have been more aware," she said.
Metro has since changed procedures and announces to all operators when trains will share a track. Track walkers must also stop inspections during single tracking. More than a dozen improvements to work procedures were put in place after the November accident, including more training, surprise safety inspections and reduced train speeds, officials said.
"The death of any Metro employee hurts us all deeply," Metro General Manager John B. Catoe Jr. said yesterday in a statement. "I am committed to turning Metro into the safest transit system in the country . . . and we will look to add more employee safeguards, including adding new technologies."
Metro safety chief Polly Hanson said she wants to try the new automatic alert technology, but some within the rail department are balking at the extra work it would require, according to Metro sources who spoke on condition of anonymity for fear of losing their jobs.
In an accident near Dupont Circle on May 14, 2006, senior mechanic Jong Won Lee, 49, was hit and killed by a southbound Red Line train about to enter the station. Lee and two other mechanics had been working on a track circuit just north of the station.
All three moved out of the way to stay clear of a northbound train that was leaving the station. As the southbound train was arriving, two men stayed in the clear, but Lee did not, either because he was not aware of the train or because he was unable to find a safe area to avoid it, investigators found.
In the accident near Eisenhower Avenue on Nov. 30, 2006, the safety board said the train operator failed to follow proper procedure to slow or stop the train, and the two track inspectors failed to maintain an effective lookout for trains. Cherry, 52, died that day, and Matthew Brooks, 36, died seven days later.
The train operator, identified in NTSB documents as Lynette Harris, was banned from operating trains or buses after the accident. She is receiving workers' compensation. After the NTSB finding, Metro spokeswoman Candace Smith said the agency is giving "serious consideration" to firing her.