The Metro safety investigator probing the Jan. 20 derailment of a Blue Line train said yesterday that transit officials will retrain 30 track inspectors, encourage more employee whistle-blowers and consider adding a new computer system to monitor maintenance records now scattered in unorganized paper files.
Fred Goodine, Metro's assistant general manager for system safety, said a six-week investigation determined that the train was running on a storage track, not designed for everyday use, that did not have metal guards to keep the train on track.
Metro's immediate response to the crash was also faulty, Goodine said. He noted that a controller's directive to the driver to move the derailed six-car train into Crystal City Station could have resulted in serious injuries or deaths.
"It could have been catastrophic," Goodine said. None of the 46 passengers was injured.
Goodine told Metro's safety committee yesterday that it could take more than three months to implement the fixes. Officials will retrain track inspectors over the next 60 days, he said. Adding restraining rails on the track near Reagan National Airport, as well as outside the rail yard at West Falls Church Station, could take more than three months, because the rails must be manufactured. The section of Blue Line track where the derailment occurred has been shut down.
Metro spokesman Ray Feldmann said employees could receive administrative sanctions, ranging from counseling and additional training to termination. Officials will decide within 30 days which employees might be cited.
Metro officials are also drafting a directive to personnel urging them to report their safety concerns up the chain of command if their supervisor does nothing.
In December, one of Metro's line quality managers noticed that Metro was running passenger trains on the track where the derailment occurred. When he objected to a supervisor, noting that the track was designed only for train storage, the supervisor did nothing.
"It was a poor judgment call," Goodine said of the supervisor's decision.
Goodine said the missteps leading to the accident date as far back as 1973, when the general contractor who built the track failed to install the required restraining rail. Metro never corrected the problem.
The track had been used occasionally for passenger train service since 1977, Goodine said, and was being used on Jan. 20 to accommodate a construction project.
Earlier that day, two Metro track inspectors noticed wear on the rail and installed a gauge rod, a piece of metal that acts as a brace, Goodine said. Although the rod tightened the tracks just a fraction of an inch, it actually made the turn sharper, reducing it by 160 feet.
As the train, which had left the airport about 8:20 p.m. and was heading toward Crystal City, approached the steep turn where the rod had been installed, it stopped momentarily because of trouble with its automatic train control.
The train then jerked forward, causing the rear wheels to pop off the track. The train moved along for 29 seconds, shuddering to a stop 620 feet away.
Goodine said the driver was "disoriented" and radioed controllers that the train had stopped outside Crystal City Station, when in fact it was still much farther out. This delayed the arrival of Arlington County fire and rescue personnel by more than 15 minutes, Goodine said
Safety investigators also recommended long-term system-wide improvements, including a computerized management system that documents all changes to equipment and facilities.
Goodine said that when investigators delved into old records for maintenance data, they found that few adequate records had been kept. In some cases, investigators had to rely on the memories of long-term employees to learn what had been done. "We had to turn over every stone," he said.