The commission’s audit included several safety concerns that have gone unresolved for years, but also noted cultural issues that investigators say created an atmosphere of racial and sexual harassment, willful ignorance of safety protocols, and low morale that has contributed to an understaffed control center.
Metro has restructured supervision of its ROCC and hired a new director for the center to combat problems. Safety Commission Chief Operating Officer Sharmila Samarasinghe said Tuesday the commission has approved 20 of 21 corrective action plans Metro was required to submit after the audit.
But she said implementing many of the fixes could take years.
“[Metro] had not made substantial progress in many of these areas over several years, so recovering from these would not be a quick task, either,” she said.
While Metro is working on transforming its ROCC, the cases the commission detailed Tuesday demonstrate problems that also include track safety and coordination between workers on the ground and in the control center.
Metro spokesman Ian Jannetta said Tuesday that as part of a culture change in the ROCC, “we are working to modify and enhance our safety protocols for accessing track,” which includes better communications training and updated technology.
On Aug. 11, a train rolled backward and inadvertently attached to another train while workers were performing tests, safety commission inspector Manuel Lopez said. Rather than leaving the scene untouched for safety investigators, a traffic controller at the rail yard told a train operator to move the trains off the track.
“The train operator correctly refused to manipulate the scene of a safety event and the event was eventually properly reported,” Lopez said.
But the incident further demonstrated why Metro must strengthen its commitment to preserve evidence, safety officials said, an issue that has been cited at least twice before by the commission.
In the audit of its Rail Operations Control Center, the commission found a lack of adequate chain-of-custody procedures for evidence recovered after incidents occur. Meanwhile, workers in October performed tests on equipment from a train separation that safety inspectors didn’t want touched.
In another incident, a track inspection team was working on the Red Line on Aug. 27 near the Takoma Park station while rail traffic hadn’t been stopped.
The team had requested a stoppage, but the ROCC told it to stand by. The team began working in the area and was surprised by an oncoming train, inspectors said.
Members of the team told safety investigators they weren’t watching for train traffic because they assumed the ROCC was watching out for them.
“Communication breakdowns, efficiency pressures and an apparent acceptance for not adhering to written procedures contributed to this event,” commission investigator Bruce Walker said Tuesday. “The investigation suggests that Metrorail has allowed procedures to be ignored. . . . This is dangerous and suggests that [Metro] must place a renewed focus on safety, promotion and safety insurance efforts to ensure that workers understand safety rules and that they properly implement those rules.”
On Sept. 3, a system maintenance and low-voltage power crew working at the Tysons station “improperly downgraded” its safety plan with the ROCC’s approval and worked while the track was energized.
“This put the crew at risk,” Walker said.
Asked why the plan was changed, Walker said an official in charge told investigators “there was not much work to do and there was no potential for the workers to contact the third rail so the reduced protection was acceptable.”
Walker countered that argument Tuesday.
“This is not accurate,” he said. “The roadway worker protection rules exist because there are risks any time the workers access the roadway.”
Metro policy allows its workers to challenge and question safety matters without fear of retribution or punishment any time they feel they are at risk.
At least one electrician told investigators “they were scared to raise a good-faith challenge due to fear of retaliation,” Walker said.
“The electricians stated that they just accept the risk and do not put their jobs on the line by making a good-faith challenge,” Walker said. “The entire point of the good-faith challenge is to save lives through a non-punitive reporting culture.”
Walker said workers are afraid of retaliation that could be as subtle as not being given as much overtime. He said in addition to employees knowing how to report safety concerns, they also must feel comfortable informing investigators about incidents of retaliation.
Jannetta said Metro “expressly prohibits retaliation,” adding that employees have multiple ways to report such issues, and it can be done confidentially.
Safety Commission Chairman Chris Hart said Metro’s safety culture needs continuous monitoring.
“Has it been remedied or is it still a problem out there? Because when people are afraid to talk, then that indicates a much deeper issue,” he said.
Commission officials also discussed findings of a recent audit on elevated structures thatdid not have weight load ratings “to confirm the number or type of trains or size of equipment that can safely travel the bridges or the elevated stations,” Samarasinghe said. She said the lack of such information can create hazards if structures become overloaded.
The audit said that while Metro has developed and published a structural inspection manual, it hasn’t trained staff on policies and procedures in the manual. The audit also said Metro officials don’t have proper structural steel inspection tools, and that structural inspection supervisors are too overloaded with other work to spend enough time in the field studying structures.
Jannetta said bridges and structures are inspected at least every two years. He said elevated structure replacement and rehabilitation is a priority in Metro’s capital construction program.
The audit cited Metro for not reviewing credentials, qualifications or training of contractors hired to do elevated structure inspections. The commission gave Metro 45 days to develop corrective action plans to address issues in the audit.