Metro News Release
For immediate release: January 23, 2008
Human error caused Metro track walker deaths
Metro changes work rules to improve employee safety
The National Transportation Safety Board (NTSB) cited human error as the probable cause in the deaths of three Metro track workers during two separate accidents in 2006. Metro has taken several steps to enhance safety since the accidents, including more training, surprise safety inspections and reduced speed limits.
“The death of any Metro employee hurts us all deeply,” said Metro General Manager John Catoe. “I am committed to turning Metro into THE safest transit system in the country. That’s why we’ve made more than a dozen improvements to work procedures to help prevent this from happening again. And we will look to add more employee safeguards, including adding new technologies.”
On May 14, 2006, Automatic Train Control Technician Jong Won Lee, 49, of Springfield, Va., was struck and killed by a Red Line train at the Dupont Circle Metrorail station.
Matthew Brooks, 36, of Waldorf, Md., and Leslie Arvell Cherry, 52, of Clinton, Md., were hit by a four-car Yellow Line train while inspecting the tracks between Huntington and Eisenhower Avenue Metrorail stations Nov. 30, 2006. Mr. Cherry died that day, and Mr. Brooks died seven days later.
The NTSB found the probable cause of the Dupont Circle accident was the failure of Mr. Lee to stand clear of the approaching train. The Safety Board determined that the probable cause of the Eisenhower Avenue accident was the failure of the track inspectors to maintain an effective lookout for trains, and of the train operator to slow or stop the train until she could be certain that the workers were aware of its approach and had moved to a safe area.
The NTSB also determined that better safeguards to protect track workers from approaching trains, more assurances that train operators were aware of track work being performed, and reducing speeds through work areas may have helped prevent the accidents. The NTSB also found Metro could have had a more aggressive program of rule compliance, testing and enforcement of its work rules.
The Safety Board recommended improving worker protection, compliance with Metro safety rules and adding technologies for additional track worker protection. Metro has already begun implementing those recommendations and is actively exploring new technologies.
Metro’s work rule changes were endorsed by the transit agency’s regulatory body, the Tri-State Oversight Committee.
“We didn’t wait for the NTSB report,” said Metro’s Deputy General Manager Gerald Francis. “We took action immediately after each of these two tragic accidents. The changes we’ve made address many of the issues raised by the NTSB, and we will make other improvements.”
The changes include requiring more communication between track workers, the Operations Control Center and train operators; limiting track inspections to non peak travel times and requiring operators to slow down while passing through work sites.
Metro also launched an authority-wide safety improvement program in early 2007, which aims to instill a stronger safety culture and cut work-related injuries and accidents in half by 2011.
“We also have requested to participate in the Federal Transit Administration’s track walker safety pilot program,” said Ron Keele, Metro’s newly hired safety chief.
Seven Metro employees have died after being struck by a train in Metro’s 30-year history.
Metro created a memorial scholarship fund in 2006 to honor employees who have died in the line of duty. Mr. Cherry’s daughter and Mr. Lee’s daughter were the first recipients to receive scholarships last year.
Metro has made the following safety improvements in direct response to the Dupont Circle and Eisenhower Avenue accidents:
• Track inspections now occur only during off-peak travel times when fewer trains are on the tracks.
• Train operators now receive additional training on rail safety procedures. Safety officers also conduct “safety blitzes” at work sites to ensure employees are aware of and are following safety rules.
• Track inspectors now must request and receive confirmation from the Operations Control Center that a train controller has set a computer command that prevents trains from going in the reverse direction on an area of track.
• Track inspectors now must contact the Operations Control Center on the radio after they leave a station or pass an interlocking, where trains switch from one track to another. The Operations Control Center in turn must repeat back to the inspector to confirm accuracy and to inform train operators in the area until personnel clear the work zone.
• All rail employees now must wear a florescent colored safety vests. Metro is piloting other high visibility apparel, such as shirts and coats.
• Train operators who have been notified that employees are on the track now must put their trains in manual mode two stations before arriving at the site of the work and must travel at speeds no faster than 35 mph.
• Officials re-enforced the procedure that if a train operator sees someone on the tracks, the operator must immediately reduce speed to 10 miles per hour and sound the horn. If the operator doesn’t see the person stand away from the track and give the proper hand signal to proceed, then the operator must stop the train.
• Train operators and track walkers have received additional training on the proper hand signals, including receiving yellow pocket reference guides.
• Audits now ensure that the Operations Control Center makes repeated announcements every 20 minutes to inform train operators where maintenance is taking place within the system. Track workers can request that those announcements be made more often and that trains operate at lower speeds in their work area if needed.
• Prior to establishing single tracking, the Operations Control Center must announce to all train operators where the single tracking is taking place and receive confirmation of the notification from personnel on the tracks. Track walkers must stop inspections and clear the area where single-tracking is taking place.
• If track workers are using equipment such as cranes or booms that could possibly pass over a train, strict procedures are followed to ensure the safety of all employees and equipment. As part of the procedures, flag persons are deployed and there is constant communication between the flag persons, the Operations Control Center and the crane operator. Also, announcements are made to train operators and if necessary, speed restrictions are imposed.
• Track walkers travel in pairs. One is the lookout and the other is inspecting the track and being mindful of passing trains. Previously, both track walkers were inspecting the track while looking out for passing trains.
• Metro has provided additional training on procedures for train operators, track workers and operations control room personnel.
• Metro is investigating whether electronic devices could give an additional warning to train operators and track workers.
Other Safety Initiatives
• Newly formed safety committees meet in rail yards and bus divisions.
• The root causes of accidents and injuries and prevention tips are shared with employees soon after they occur.
• Metro is revising safety procedures to make them more reader friendly.
• Metro holds meetings between the unions and management to address safety issues.
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News release issued at 12:00 am, January 23, 2008.