He did so despite being under a “zero speed” command, meaning he wasn’t authorized to move without getting permission from the operations control center, Metro said.
The train was going 11 miles per hour; the operators were treated for minor injuries, and no passengers were on board.
The investigation has unearthed a number of safety problems, according to the Washington Metrorail Safety Commission, some of which are relevant to this particular crash, some of which aren’t and some in which things are not yet clear.
For example, the commission found that there are a number of places in the rail network where the system does not tell operators how fast they should be traveling. Such “speed commands” are supposed to be displayed on the console used by the operator.
But “there are several mainline locations in which train operators routinely ‘lose’ these speed commands,” the commission said.
This happens because of “rail that has different metallurgical properties,” according to the commission, and the result is the potential for more “unauthorized” train movements.
Commission chief executive David L. Mayer said the stretch of track near Farragut West where the crash occurred is not known to be one of those problem spots, but he said the issue is a concern that needs to be addressed nevertheless.
Metro should create a map or other inventory of these spots and come up with plans for “correcting these defects,” the commission said.
The commission also noted that “one of the issues in the investigation . . . is whether the use of Personal Electronic Devices (PEDs) may have played a role in distracting the operator of the striking train.”
Mayer emphasized that the investigation has not found that the operator was using such a device.
But the probe, he said, “has revealed opportunities for Metrorail to strengthen its efforts to prevent use” of cellphones or other devices.
One concern, Mayer said, is that “no determination may be possible” on the question, because investigators have faced problems getting data related to any such devices in this case.
“I wish data were more readily available,” Mayer said. “I don’t have any reason to believe this is an issue that’s unique to Metrorail. I don’t know that any transit operator really has the kind of access I’d like to see to electronic-device records when such records are created.”
The commission found that Metro should “require employees to turn over (or cause to be turned over) devices and records upon request” and develop “a program to actively detect unauthorized presence and use of electronic devices through video review, inspection, and efficiency testing,” among other measures.
Metro declined to address questions about the findings. Spokesman Ian Jannetta said the agency “will thoroughly review today’s findings and develop Corrective Action Plans while continuing our ongoing dialogue” with the commission to address concerns.
The commission also issued a finding that did not stem from last month’s crash.
It said Metro appears to have experienced an increased number of “station overruns” — cases in which the train operator “either stops past the platform end gate, or travels through the station without stopping.”
Last year, there were 34 such overruns. So far this year, there have been 48.
Mayer said it’s possible that differences in data collection may account for the increase. But whether or not the number of cases keeps rising, he said, there are too many of them.
Each of the overruns “represents an instance in which a train was not being controlled as it should have been,” the commission found.
Such a lack of control “could lead to a collision with a train or workers on the track ahead or could lead to a train exceeding track speed and/or passing a red signal, any of which could cause a derailment or other safety event.”
Indeed, the commission pointed to two recent cases of operators traveling through red stop signals.
On Oct. 20, a train went through a red signal at the New Carrollton station platform. And on Nov. 17, a train went past a red signal on a “tail track” at the Largo Town Center station.
A commission spokesman did not immediately have further details. But the commission noted that in both instances, the trains had a new software change, the “Mode Awareness Tool,” that was supposed to help address such problems. But the incidents show that the tool, while a welcome addition, “is not sufficient” for dealing with all safety issues that may arise, the commission said.