NTSB report offers harsh assessment of D.C. transit organization
In May, the National Transportation Safety Board (NTSB) released a scathing report on the January 2015 “smoke crisis” in the city’s subway system that resulted in the death of one person and scores more being hospitalized. In addition to its 43 findings and 31 recommendations, the report also identified an array of high-level safety issues. The following is an excerpt from a report summary:
The investigation of this accident revealed a range of safety issues and conditions at the Washington Metropolitan Area Transit Authority (WMATA) that illustrate the transit organization’s lack of a safety culture:
WMATA response to smoke report. A smoke detector near the location of the heavy smoke activated at 3:04 p.m. but was not displayed at the Rail Operations Control Center (ROCC) because of a loose wire that prevented communication with the Advanced Information Management System. Other nearby smoke detectors activated later, and those were displayed at the ROCC, but WMATA had no procedures for response to smoke detector activations. WMATA’s standard operating procedure states that at the first report of smoke, all trains should be stopped in both directions, but this did not happen on the day of the accident. Instead, the ROCC told the operator of a train carrying revenue passengers to look for smoke, which was WMATA’s routine response to reports of smoke or fire.
Tunnel ventilation. The WMATA station and tunnel ventilation systems were designed in the 1970s when no industry standard existed for emergency ventilations for subway transit systems. The systems were designed for heat removal and temperature control, not for emergency smoke removal. Over the years since WMATA began operation, several studies have identified the need for emergency smoke removal and have recommended increasing the capacity of ventilation fans. Investigators learned that control operators in the ROCC were not trained on strategies for configuring station and tunnel ventilation fans, and therefore, on the day of the accident, the under-platform fans in the L’Enfant Plaza station were turned on in exhaust mode, blanketing train 302 in smoke and pulling smoke into the station.
Railcar ventilation. WMATA did not instruct train operators how to shut down the railcar ventilation systems because there was no written procedure. In addition, operators had to ask the ROCC for permission to shut them down, and then the ROCC provided the specific steps to the train operators. However, those steps did not shut down all the ventilation systems on all the cars immediately. Therefore, on the day of the accident, smoke was pulled into most of the railcars on train 302 through the fresh-air intakes.
Emergency response. On the day of the accident, the District of Columbia Office of Unified Communications, which maintains the 911 emergency call system, was slow in processing the first 911 call reporting the smoke. First responders reported that when they arrived at the L’Enfant Plaza station, they were directed to the wrong tunnel to look for train 302. Evacuating passengers reported that egress through the tunnel was difficult because of dim lighting and obstacles along the safety walkway. The [incident commander] appeared to ignore the WMATA Metro Transit Police incident commander and did not take into account the multiple agencies involved in the response and the consequent need for elevation to a Unified Command structure.
Oversight and Management. In the years since the 2009 accident at Fort Totten, substantial improvements have not been made, and many of the same safety management deficiencies remain today. The Tri-State Oversight Committee (TOC) has lacked sufficient resources, technical capacity, and enforcement authority to provide the level of oversight needed to ensure safety at WMATA. The TOC also has not met the requirements of the Moving Ahead for Progress in the 21st Century Act (MAP-21) that was enacted in 2012. This accident also identified deficiencies in the safety oversight of WMATA by the Federal Transit Administration.