In January 1996, a train operator, Mr. Callands, was killed at Shady Grove station (A15) when his train slid on icy tracks and collided with a ‘gap train’ (a spare train) that was parked behind (north of) the station.
Both the Federal Transit Agency (FTA) and the National Transportation Safety Board (NTSB) investigated and published reports.
The NTSB report can be found here.
The FTA report is here.
As with many accidents at Metro, this one should never have happened. Someone in upper management, Mr. B, who was more concerned about ‘flats’ (from wheels sliding on the rail) than he was about safety had issued a directive stating that operators were never to operate in manual except for in emergencies (emergencies which were never defined).
The day Callands died there was a blizzard and trains were overrunning (sliding through) stations. He repeatedly asked for permission to operate in manual mode but Central Control (OCC) refused. One of his last radio transmissions was at Rockville (A14). When his train overran the platform there he ‘keyed down’ (like taking the keys out of the ignition in a car) in order to open the doors and service the station. He asked one last time for permission to run in manual but OCC wouldn’t budge. They were terrified of the wrath of Mr. B.
Mr. Callands didn’t realize it, but when he keyed up his train it lost the Automatic Train Supervision (ATS) speed of 50 mph that OCC had been sending. Instead, his train was governed by the maximum Automatic Train Protection (ATP) speed in that area which is 75 mph. From the FTA report:
“The problem of lost commands after a station overrun was known to WMATA technical and OCC personnel. As the system was designed, if a restrictive command was lost in ATO, the system defaulted to the highest command permissible based on track occupancy. This effectively violated the fail-safe principle and made ATO operation under conditions of poor adhesion unsafe. This was unappreciated, unrecognized, or ignored by WMATA management.
As with all other rail transit agencies, WMATA’s system design and operating book of rules recognized the possibility of the ATP system failing and placed ultimate control of train stopping in the hands of the train operator. An operator can assume manual control of a train and control braking, and the book of rules requires that he or she do so if train braking performance under ATO is deemed unsatisfactory. Even remaining in ATO, an operator can apply emergency brakes by depressing an emergency stop button, called the “mushroom” at WMATA.
Management contravened the Book of Rules by directing that operators were to obtain permission from the Operations Control Center before assuming manual control. OCC personnel were directed not to allow manual operation, except in an emergency. There was no definition of an emergency, nor could it be expected that OCC personnel would be able to make the same judgments as to track conditions on individual train braking performance as the individual train operators.
Further. the OCC personnel were aware that the intent of the directive was to prevent manual operation during wet weather. As a result, when manual operation was needed to provide safe stopping distances — a situation that should be considered an emergency -OCC personnel were “programmed” not to consider that an emergency under which manual operation was to be permitted.
All this is in spite of findings in a 1988 Battelle report on the Breda Car Microprocessor and Software Systems specifically pointing to the need for ultimate manual control. This report identified certain conditions that “could produce a lower than intended level of braking under the abnormal mode of operation.” They went on to state that the conditions “are not inherently unsafe since the train operator has ultimate responsibility for safe operation of the train.” It is clear that when an ATP system is designed to place ultimate control in the hands of the train operator, directing otherwise makes the system inherently unsafe. This was recognized by some experienced train operators, if not by management. During our interviews, some train operators made off-the-record statements that they disobeyed the directive not to go to manual operation without permission, when they felt braking performance under ATO was inadequate
Needless to say, a rail transit system where operating personnel feel compelled to disobey formal directives promulgated by management because they feel such directives compromise basic safety, is a system that is very much in complete disarray.”
When he got to A15 his train went barreling through the interlocking, past the platform, and slammed into the gap train.
The gap train should not have been parked there but it was more convenient.
The area where the wreck happened is shown in the photos in the “Dan Jones Gate Saga” post.
As a result of that accident (and a few others) the FTA conducted a review of safety and operational issues at WMATA.
It is scathing. Blistering. In fact, if Metro weren’t so critical to the functioning of the nation’s capital, any reasonable person reading this report would come to the conclusion that the entire Metrorail system should have been shut down immediately.
The report itself is incredibly damning but what is inexcusable — criminal — is that so little has changed in the 13+ years since it was released. In fact, this report mentions several problems that were reported a decade or more earlier that had not been adequately addressed:
WMATA’S CORPORATE CULTURE
The effectiveness of WMATA’s safety programs has been limited by what might be called the agency’s corporate culture. The areas of primary concern are:
- the lack of rail transit perspective throughout the organization
- the lack of understanding of system safety concepts and responsibilities at all levels of the agency
- the absence of an effective system of checks and balances to identify and correct problems
These attitudes and problems have a long history. As early as 1985, one study identified beliefs that “task completion is more important than task quality,” resulting in, among others, incomplete preventive and corrective maintenance. It also found that middle managers were uncertain as to their responsibilities and authority.
This culture has permeated the agency, and limits initiative and effective action. Its correction is a long-term effort that will require continuous attention.
Relationship of this Review to Other Studies
As a result of the Shady Grove accident, several investigations, both internal and external, were initiated. These include:
- a WMATA internal review of the safety organization completed in June, 1996
- the NTSB’s Shady Grove Investigation, October 29, 1996
- a WMATA internal report, “Collision of Train No. 111 at Shady Grove Station on January 6, 1996,” October 17, 1996
In addition, as discussed in the body of this report, WMATA has been the subject of other safety-related investigations, audits, and reviews over the course of its history.
While it is beyond the scope of this study to confirm independently the results of these other investigations, many of their most important conclusions were found to be accurate. This review team was troubled to find that many of the recommendations of earlier studies were not implemented, or if implemented, were not effective in solving the problems they were intended to solve. Furthermore, where scorecards were maintained on the status of past recommendations, such as in the NTSB report of a 1982 fatal accident, many recommendations including those marked by the NTSB as “Closed-Acceptable Action” were found not to be currently in place. This important issue is discussed in detail in Section III.
WMATA fails to make effective use of outside analyses and reviews.
WMATA has been the object of numerous studies by external agencies. Many of these have repeatedly identified the same problems. Yet, at the time of the Shady Grove accident, such remedial action as may have been taken in some areas, was no longer in effect. This is most recently illustrated in the NTSB’s investigation of Shady Grove, where the recommendations of a 1982 accident investigation are included as an appendix to the Shady Grove accident report.
- Numerous sound recommendations from an NTSB accident report of 1982 are not currently operative.
In 1982, a fatal accident at WMATA was the subject of a thorough NTSB investigation that included important safety-related recommendations. Almost all of these are indicated by NTSB to have the status “Closed – Acceptable Action. While many of these recommendations may indeed have been adopted on the dates indicated in the NTSB report, they are no longer in effect. Either they were implemented ineffectively, or they were gradually allowed to lapse.
[The report goes on to list seven (7) recommendations that were never implemented, including this one]:
- A 1985 Booz-Allen appraisal of the Department of Rail Services and its quality assurance function identified problems that were still in place at the time of the Shady Grove accident.
As one of the key findings of its review, this consultant found that the Department of Rail Services “has serious infrastructural weaknesses that without rectification will inhibit the implementation of a balanced quality assurance program.” The report found that the weaknesses pervade the organization, resulting in a general perception by employees that “task completion is more important than task quality. ” This, in turn, was found to result in incomplete preventive and corrective maintenance, incomplete analysis and reporting, loose application of standards, and inadequate technical support, among others.
This 12-year-old report found deficiencies in administration that are identical to those discussed in Section IV (Command, Communication, and Control). In particular, that “many key personnel are not sure what their superiors expect of them, what they are accountable for, or what their authority is.”
- At WMATA, verbal instructions are given to operating personnel.
The NTSB Report on the Shady Grove accident includes two conclusions about management’s use of verbal instructions and their contribution to the accident. The report also includes a recommendation to discontinue the practice. This recommendation is virtually identical to a recommendation the National Transportation Safety Board (NTSB) issued in its investigation of a 1982 fatal accident at WMATA; this recommendation was indicated as being “Closed – Acceptable Action 12/15/82.”
There was confusion at all levels of the agency with respect to the chain of command and the authority and responsibilities of managers.
In its 1985 review of WMATA’s quality assurance efforts, Booz-Allenidentified serious management deficiencies that were still present at WMATA at the time of the Shady Grove accident:
Key personnel are not sure what their superiors expect of them, what they are accountable for, or what their authority is. This results in a reduction of management credibility and efficiency at all levels. Problems are routinely elevated to higher authority for resolution.
In 1997, the newly installed General Manager and his new Deputy General Manager identified lack of management initiative as one of the major problems they faced.
WMATA management has failed to take “ownership ” of recommendations that should have been integrated into WMATA ‘s operating culture.
After the fatal 1982 accident, WMATA accepted and apparently adopted most of the recommendations made by the NTSB in their report on the accident. Over the years, however, ineffective implementation, backsliding, or a lack of monitoring has led to a return to some of the conditions that existed prior to the accident. For example, NTSB R82-063 recommended that WMATA “eliminate the practice of issuing verbal instructions to the Metrorail operations control center personnel which modify or amend operating rules and standard operating procedures.” WMATA accepted this recommendation and the NTSB indicated it as “Closed – Acceptable Action” on 12/15/82. Personnel interviewed for this study reported that prior to the Shady Grove accident it had once again become common practice for verbal orders to be given. Fourteen years after WMATA supposedly put procedures in place to implement the recommendation, the NTSB had to repeat it, virtually verbatim, after Shady Grove. Another recommendation, R-82-077, was for WMATA “in conjunction with the District ofColumbia fire department, [to] expand the scope and frequency of the disaster crash simulations and include hospitals and fire/rescue units from surrounding jurisdictions.” WMATA accepted this recommendation and the NTSB closed it out.
The NTSB closes out a recommendation on the basis of reports it receives from the agency involved. It does not, as a general practice, audit the agency’s efforts. Hence, NTSB’s closing the recommendation indicates that WMATA said it had appropriate procedures in place. Personnel interviewed stated that disaster simulations were infrequently held and generally did not include outside agencies. After the Shady Grove accident, the NTSB had to repeat the recommendation. (Recommendation R-96-44, “increase the frequency of command and control exercises conducted jointly between the Washington Metropolitan Area Transit Authority and the emergency rescue services of all jurisdictions served by the Metrorail system.”)
These and other examples demonstrate a failure of management to fully adopt sound recommendations that address serious problems in a full and continuing way.
This is just a small sampling of what is contained in the FTA report.
Too bad they have no control over WMATA.
WMATA answers to no one. It is a rogue agency that that can only be reigned in by congress.
“We regret the inconvenience.”