Metro operator No. 012008 had been on the job for eight months when she hopped into the cab of the wrong train on July 4, hit the power and ran a red light on her way to pick up passengers headed for celebrations on the Mall.
Two months later, in September 2014, a Silver Line train operator with 11 years of experience rolled through a red signal and stopped just before a stretch of track that seconds earlier had an oncoming train.
This month , an operator ran a light near the Smithsonian Metro station and came to a stop only after realizing that his train was on a collision course with another train. He stopped 189 feet short of the second train, which was waiting at the platform, loaded with passengers.
There have been at least 47 “red signal violations” since the beginning of 2012, according to the Federal Transit Administration, which took responsibility for the safety of Metro’s rail system last year and cited the “pervasiveness and seriousness of this problem,” despite years of warnings and efforts to address it.
The question is: Why? How can something so critical, and potentially dangerous, keep happening?
The answer, according to dozens of incident reports and the results of an outside investigation obtained through public records requests, has plenty of intricacies and contributing factors, and one unifying theme: Like most of us, Metrorail train operators sometimes tune out and get lost in their thoughts. The difference is that they are responsible for the lives of hundreds of people riding in 200-ton trains. Sometimes they sink into habit, move by instinct and fail to see what’s right before their eyes, investigators found.
The repeated human errors, and their effect on safety, prompted Metro officials to hire a neuroscientist and an outside safety expert to try to tease out exactly what is causing the lapses. While the hazards of multitasking, such as using a cellphone while driving, are well known, researchers have found that simply thinking about something else is enough to be a real distraction.
“A lot of times, people don’t realize that when they’re tuning out — and it can be something as simple as mind wandering — people don’t realize this actually puts them at risk,” said Daniel Smilek, an associate professor of cognitive neuroscience at the University of Waterloo in Ontario.
Smilek and partner Randall Jamieson, who run the Atticus Consulting Group, were hired by Metro to help translate the latest academic findings to the transit agency’s real-world problem. “We can show that basically whenever you mind wander, even in very simple tasks, your performance will deteriorate in those tasks,” Smilek said.
The draft findings from their investigation point to numerous “attention-related errors.” Time after time, Metro operators took off from a platform or other stop “without full conscious awareness” of what they were doing, the consultants found. Operators, supervisors and managers also lack an “understanding of how human attention works and under what circumstances it is likely to fail.”
Similar challenges trouble Transportation Security Administration agents gazing at X-ray images and surgeons peering into incisions. But for Metro, which faces broader management and safety issues highlighted by its botched handling of a deadly smoke incident last year, the problem has raised concerns about whether other safety procedures are being followed.
The Tri-State Oversight Committee, a safety panel made up of officials from Maryland, Virginia and the District, has pressed Metro for years to tackle the problem aggressively, arguing that whatever it is about Metro that allows repeated red-light running could also lead to unsafe behavior elsewhere.
“We would characterize all red signal violations as a hazardous circumstance, close call, or near miss,” the oversight group said in a statement. “Such patterns of noncompliance may indicate systemic issues regarding the culture of rule compliance and enforcement.”
What one operator called “a big rush-rush culture” in the nation’s second-busiest subway proved to be “a significant systemic cause” in most cases of red-light running, the Atticus investigation concluded. The report also pointed to inadequate supervision of operators and controllers, leading to continued miscommunication.
The causes are multifaceted, and even those at fault sometimes cannot believe what investigators found.
An operator who ran a red light between the Reagan National Airport and Crystal City Metro stations in August 2014 became “extremely defensive” when pressed on the circumstances, according to the report.
He insisted that he had not run the red light. He was certain he had the rail equivalent of a green light.
But a technical re-creation provided “irrefutable evidence to the contrary,” according to the consultants, who said they were worried about the operator’s “ongoing refusal” to acknowledge his responsibility — or reality.
So they walked him through it, framed more as a lesson than an inquisition.
The root cause? He made his train announcements, shut the doors, sat down and immediately pushed the accelerator without paying proper attention.
There also was a critical “perceptual error.”
Metro was single-tracking, meaning that trains going opposite directions must wait their turn. Based on experience, they found, the operator “had the expectation that he would depart” just after the opposing train arrived.
Which he did. Right through a red light.
He had no idea a second train was trailing the first, also headed his way. Additional safety systems kicked in, and he was instructed to pull back out of the way.
The consultants also cited a “systemic cause.”
It “may have been prudent,” they wrote, for the Rail Operations Control Center to share more information. It was a “novel situation” to be “fleeting” a pair of trains toward the airport, and the operator could have used that information.
Metro officials emphasize that they have a multilayered system to keep passengers safe, including technology designed to stop trains when humans fall short. And oversight officials say they have seen no examples of the automated technology failing in red-light incidents.
But the systems don’t help in all situations.
In this month’s incident near Smithsonian, the train was moving in the reverse direction to avoid a problem ahead. The operator misheard an instruction from his controller about which station to go to. When the operator repeated the mangled instruction, the controller didn’t catch the mistake, allowing the operator to head toward the wrong station. While headed there, he ran the red-light signal.
The safety system does not take over in such circumstances, officials said. But the operator, traveling at 10 mph, was able to stop in time.
Metro’s deputy general manager, Rob Troup, in an interview Feb. 11, hours before announcing his resignation, said behavioral concerns are universal. In recent years, Metro increased training and added placards in train cabs reminding operators that red means “STOP YOUR TRAIN.”
In “every operating environment — whether it be aviation, freight railroads, transit railroads, class-one railroads, truck drivers, it doesn’t matter — the human-error element is the hardest thing that you deal with,” Troup said. Management, engineering, audits, rules and procedures all have a role in eliminating the incidents, he said.
Citing “an exchange of information we have with other properties,” Troup said that Metro has “significantly” fewer red-light violations than its peers, although he declined to name the other systems. Still, he said, “it’s not acceptable to me. One is not acceptable to me.”
The Federal Transit Administration said in a statement that such violations are not systematically reported to its transit database, making it “difficult to compare different rail transit agencies.”
Still, the Washington Metropolitan Area Transit Authority has a problem, the FTA said.
“Red signal violations are a serious safety concern and WMATA’s trend line is going in the wrong direction. WMATA had more red signal overruns in 2015 than in either of the preceding two years,” according to the statement.
Back on July 4, 2014, things were “particularly hectic” at the Shady Grove rail yard in suburban Maryland, the consultants found.
An official responsible for guiding train operators through the vast yard was distracted by a disabled train and the gargantuan task of carrying tens of thousands of holiday revelers. It was also operator No. 012008’s first time working there.
She was supposed to hop aboard a train on Track 15 but boarded one on Track 14 instead.
The operator twice radioed the operations official with the number of the signal in front of her, a basic safety step. But the official didn’t notice that she was saying the wrong signal number, because she was on the wrong track, and didn’t try to stop her.
The operator said later that she “was just trusting the tower” when she hit the accelerator. No one was hurt. The guiding official was “disqualified” from the job. The operator was retrained.
The consultants, hired for $19,800, reexamined and rewrote 11 of Metro’s investigative reports and found that officials rarely delved into crucial questions of mental readiness and sometimes reached the wrong conclusion.
In one case, Metro officials told an operator traveling for the first time in a District rail yard that “you were not focused and paying attention to the safe operation of your train.”
But the consultants said the new operator was actually so anxious about being on unfamiliar ground and so focused on finding the right place to stop that he was “effectively psychologically blind” to the red light.
Another operator was, in essence, too familiar with the station where she ran the light.
“The more you do it, the more you relax from thinking,” she told the Atticus investigators, who concluded that as time goes by, she is “likely to rely on her habitual, routine past experiences — in other words ‘operating on autopilot.’ ”
For a Silver Line operator and 11-year veteran, her near miss came after a supervisor cut short her break and then spurred her further by saying she was “due off platform a couple minutes ago,” the consultants found.
To address the “big rush-rush culture,” Metro recently tweaked its schedule to allow operators more time to do train walk-arounds and safety checks before their first run. Metro also set up a new system in which operators can hand off their train to a fresh colleague at the end of the line “should an operator need relief.”
After finding examples of stress and excitability among operators, Atticus also said operators need better training to handle such “adverse mental states.” Metro is considering that.
Minutes before her break was truncated, the Silver Line operator had another jolt. Her supervisor told her that she must “submit an incident report in response to a complaint that had been levied against her by a fellow employee as a result of an altercation” that day, the report said.
Just before she ran the light, she was worrying about being disciplined, she recalled, although she didn’t think it caused her mistake. The consultants weren’t so sure. They said they have investigated numerous errors “shortly after a worrisome or disturbing communication” from a boss or relative.
When you’re thinking about something other than the job at hand, Smilek said, “some of your processing capacity is taken up,” particularly when something affects you deeply. Like a bank account, a brain’s processing power has limits, he said. “You can’t allocate it to too many things, otherwise you just run out of money.”