A new Washington Metrorail Safety Commission report paints the Rail Operations Control Center as a chaotic “toxic workplace culture” beset by “sexual comments, harassment and other unprofessional behavior such as attempts to manipulate safety event investigations that create unacceptable safety risks.”
The audit immediately points to the fatal 2009 Fort Totten crash that killed nine people as well as the deadly 2015 L’Enfant Plaza smoke incident that left one rider dead. And it states that the ROCC, which functions as the nerve center of the Metro system, has yet to create “an effective safety culture” — which puts all riders at risk.
“Metrorail has not followed its own fatigue management policies that require at least one day off per week, has not addressed recurring safety issues, and has not implemented adequate recruitment, hiring and training practices,” the report states.
The report, published Tuesday, continuously calls into question Metro’s dedication to safety over the course of 50 pages.
The report is based, in part, on more than two dozen ROCC employees, including nearly all of the controllers who were employed in the center as of March. Controllers decried a lack of structure in the control center and said managers regularly cursed and yelled at them, made racist and homophobic remarks and made explicit sexual remarks toward female employees.
The report found that ROCC management even “baselessly threatened” to fire or even arrest controllers for asking questions of management or for properly following procedures.
“Unfortunately, the December incident bore many of the same hallmarks of the 2015 L’Enfant Plaza smoke accident. So It concerned us greatly and that’s why we issued findings both in December and May, not waiting to publish the audit … We wanted to get it in Metro’s hands rapidly so they could begin to make fixes,” Commission CEO David Meyer said during a news conference.
Metro now has 45 days to being to address 21 findings that the safety commissions says require corrective action by the transit agency.
While the safety commission was conducting its audit, it reported three issues in May that it said required immediate action.
Among the issues: controllers reported they were routinely rushed to restore third-rail power after it had been disconnected — because of a focus on restoring train service rather than following safety procedures. Controllers said they were rushed to bring power back up even when first responders were still on the tracks, according to the report.
Following the commission’s findings in May, the ROCC director was reassigned to a different position, but the latest report concludes, “Despite some possible steps forward, Metrorail has not accomplished the necessary cultural change in the ROCC.”
Despite fatal #wmata accidents, numerous NTSB and FTA reviews, and other investigations that repeatedly raised alarms, ROCC management has still not created an effective safety culture. https://t.co/Fl8DhNVb2J
— Max Smith (@amaxsmith) September 8, 2020
21 key findings
The 21 key WMSC findings from the new audit, per WMATA, are the following:
- 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 front line 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 or OAPs 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 or ROIC. 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.”
Washington Metrorail’s full audit is available online.
WTOP’s Jack Moore and Megan Cloherty contributed to this report.
