Metro Safety Commission Finds ‘Distractions, Fear, Threats and Conflicting Instructions’ in Control Center

An audit of Metro’s Rail Operations Control Center, the heart of the Metrorail system, found that despite multiple fatal accidents the center still operates in an atmosphere of distractions, fear, threats and conflicting instructions with overworked and undertrained controllers.

The Washington Metrorail Safety Commission is an independent entity tasked with overseeing and enforcing safety improvements in the Washington Metropolitan Area Transit Authority, or Metro. At the beginning of the year, the commission launched an audit of the Rail Operations Control Center or ROCC, which directs all trains and personnel across Metro’s main lines, as well as overseeing signals, elevators and escalators, car maintenance, emergency response and other operations.

Since the audit began in January, the center has seen workers alternating between the primary and backup facility to reduce the chance of passing on the virus that causes COVID-19, as well as a fire that closed the backup facility for several days in May. The commission’s work has included extensive interviews, reviewing documentation, observating operations, and reviewing radio and communications records, among other work.

The commission released some findings in May. Metro’s plans to address those findings, according to the commission, were unsatisfactory, although the director of the operations center at that time was removed.

On Sept. 8, the commission released 21 new findings. Those included looking back at the center’s chaotic response to previous emergencies, such as a fatal accident in 2015 near L’Enfant Plaza Station. A controller at that time told the National Transportation Safety Board of chaos in the operations center, and is quoted saying “the right hand did not know what the left hand was doing.”

According to the safety audit:

“ROCC management contributes to a chaotic environment. Use of profanities, threats and racial, sexual or other forms of harassment are regular features of the control center’s environment, which makes it difficult for controllers to do their jobs and drives low morale and significant turnover.

“ROCC management attempts to manipulate safety event investigations and baselessly threatens controllers with arrest or termination.

“Metrorail does not record all critical ROCC communications, limiting the lessons that can be learned from safety events.

“There is no consistent, clear, concise, immediate and reliable Metrorail communication process for safety-critical information between Metrorail personnel and the fire liaison.

“Some Metrorail procedures lack the required urgency to address life-safety issues.

“Repeated failures to address safety issues have contributed to a culture where frontline workers no longer see any value in reporting and recording problems.

“WMATA does not always follow or clearly define its fatigue risk management procedures for the Rail Operations Control Center, including those limiting the length of controller shifts.

“Metrorail’s ROCC recruitment and retention approach is failing. Some controller trainees have left the ROCC immediately after or shortly after the training course, which is scheduled to last nine months.

“A high rate of staff turnover in the Rail Operations Control Center contributes to staffing challenges and a lack of positive institutional knowledge that can contribute to safety challenges.

“Controllers still have too many responsibilities and are frequently rushed to complete tasks by management.

“WMATA has failed to regularly update the Rail Operations Control Center Procedures Manual.

“WMATA has not reviewed SOPs [Standard Operating Procedures] or OAPs [Operations Administrative Procedures] on a regular basis.

 “Ride alongs are not effectively utilized to increase controller knowledge, contributing to a lack of controller understanding of what is actually happening on the roadway.

“Controllers are not provided with the full extent of training necessary to do their jobs, including sufficient familiarization with roadway operations and procedures.

“Aspects of ROCC training are inconsistent and must be structured. Multiple controllers reported that significant time is wasted during initial training.

“Required on the job training (OJT) is not carried out in a structured or standardized fashion.

“Not all controllers experience emergency drills. If each ROCC controller does not get this experience, it diminishes the value of the drills.

“The certification process for ROCC instructors, assistant superintendents, superintendents and controllers is inconsistent, not properly documented, and lacks proper controls to ensure the integrity and meaning of certification.

“Certification and recertification scenarios required of ROCC employees are repeated year after year, diminishing the value of the testing and training process.

“WMATA does not have a standardized training program for personnel working at desks such as the MOC [Maintenance Operations Center] or ROIC [Rail Operations Information Center]. Metrorail could not provide any documentation of MOC training materials, a curriculum or a training description. Metrorail provided only a study guide for the ROIC.

WMATA does not have minimum training requirements for Metrorail employees or contractors who serve in the fire liaison position.”

Despite some steps forward since the commission began its work, the audit reports, Metro has not achieved the cultural change necessary in the operations center to keep its riders safe.

Metro is now required to provide plans to correct those findings.

Read the full report here.

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