NTSB: Fatal Metro Incident Caused by Overlooked Short Circuit

PHOTO: LesleyJLopez via Twitter

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An overlooked short circuit that caused thick smoke and the subsequent death of an Alexandria mother of two was due to Inadequate safety oversight by Metro, the National Transportation Safety Board said Tuesday.

A short circuit on Washington’s Metrorail system that caused thick smoke to fill a stranded train, killing passenger Carol Glover, a woman from Alexandria, and injuring 91 people on Jan. 12, 2015, was the result of WMATA failing to follow its own safety procedures and inadequate safety oversight by the Tri-State Oversight Committee and the Federal Transit Administration, according to a report adopted Tuesday in a public meeting of the National Transportation Safety Board.

Glover was the 61-year old mother of two sons; she lived in Alexandria, off of Taney Avenue, and had taken the Metro for more than 20 years to her job. She was riding the Yellow Line home the day of the incident.

'Perfect storm of failure'

“NTSB investigators outlined a perfect storm of failure, coupled with systemic deficiencies throughout the first response network,” said Congressman Don Beyer (D-8th). “I strongly encourage Metro leadership to make whatever personnel changes are necessary to prioritize rider safety. We cannot jeopardize passenger lives."

"It has been more than a year since the Yellow Line tragedy at L’Enfant Plaza, and today’s final report by the National Transportation Safety Board on its exhaustive investigation once again brings to the fore the painful and shocking memories of that day, which resulted in the death of Northern Virginia’s Carol Glover and injuries to dozens of other riders," Congressman Gerry Connolly (D-11th) said.

One of the more frightening revelations: Trains loaded with passengers were routinely sent to check on reports of smoke.

There was no official reaction Tuesday from Metro about the report of sending trains with passengers to check on fire and smoke (Patch left a message with Metro for a request for comment on the revelation).

'Outrageous practice'

Connolly, whose constituents ride the Metro daily into DC, was swift to condemn what he called an "outrageous practice."

"It is particularly appalling to learn Metro’s response to reports of smoke was to send trains loaded with passengers into a tunnel to investigate. I am relieved such an outrageous practice is no longer in place, but the mere fact it once existed speaks to the level of indifference to safety that had permeated the agency."

The NTSB chair said the fatal accident last year revealed a "dysfunctional culture."

“From WMATA’s lack of certain safety procedures and its deviation from established ones, this accident reveals a compromised safety system and a dysfunctional organizational culture,” said NTSB Chairman Christopher A. Hart.

Virginia's Senators Mark Warner and Tim Kaine issued a joint statement Tuesday about the NTSB report:

“More than fifteen months after the smoke incident at L’Enfant Plaza, we are extremely disturbed that many of the safety hazards that allowed that deadly accident to occur have not yet been addressed. As the report states, responsibility for this incident, which resulted in the death of an Alexandria resident, is borne not just by Metro but other regional stakeholders. We urge Metro, the Federal Transit Administration, and regional authorities to move as urgently as possible to ensure that the problems identified in this report finally get fixed once and for all.

“Since that tragedy, a new management team has taken over at WMATA; the FTA has temporarily assumed direct safety oversight; and the federal members of the WMATA Board have been replaced. These steps must be the start of a sustained effort to overhaul Metro. As Congress grapples with the long-term federal role in funding Metro, the best case we could make to our colleagues would be tangible progress by WMATA management on addressing every deficiency identified in this report.”

WMATA "failed to learn safety lessons"

In a nearly 200-page report, investigators presented findings that called into question WMATA’s ability to apply the information gained since 1982 through 12 accidents previously investigated by the NTSB, eight of which involved fatalities. “The NTSB concludes that WMATA has failed to learn safety lessons from NTSB studies and accident investigation reports,” the report stated.

The short circuit in the January 2015 accident resulted from WMATA’s failure to follow its procedures for washing tunnels and constructing power cable connector assemblies, the NTSB noted. NTSB investigators said if WMATA had followed its standard operating procedures, stopping all trains at the first report of smoke, the accident train would not have been trapped in the smoke-filled tunnel.

Control center "in a chaotic state"

The NTSB investigation also showed that the WMATA control center was in a chaotic state as the emergency unfolded. “The right hand didn’t know what the left hand was doing,” one control operator told investigators.

The report cited safety vulnerabilities throughout the WMATA system, including:

• infrastructure maintenance
• tunnel ventilation
• railcar ventilation
• responses to reports of smoke
• management deficiencies

The investigation also found that the Federal Transit Administration’s ability to compel safety compliance is not equal to that of the Federal Railroad Administration because the Federal Transit Administration’s safety authority does not wield the same regulatory enforcement tools as the Federal Railroad Administration.

“Transforming a culture where deviations from the very procedures designed to keep people safe is the norm, to a culture that is intolerant of compromises in safety is a significant challenge for WMATA,” said Hart. “But that kind of change can be done and it must be done for the sake of all, including me, who ride on this metro system.”

The NTSB issued 31 new safety recommendations in the report. In addition, nine safety recommendations were previously issued. The Washington Metropolitan Area Transit Authority received 23 of the new recommendations. Also receiving safety recommendations were the Federal Transit Administration, the mayor of the District of Columbia, the D.C. Office of Unified Communications, the D.C. Fire and Emergency Medical Services Department, and the National Capital Region Emergency Preparedness Council.

The accident synopsis, findings, probable cause and safety recommendations are available at: http://www.ntsb.gov/news/events/Documents/Abstract_DCA15FR004.pdf

The complete report will be available on the NTSB website in several weeks.