Professionalism/Fort Totten Metro Crash

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Introduction[edit | edit source]

The Fort Totten Metro Crash is a lens to professionalism. It analyzes a preventable accident and the steps that led to a catastrophic failure. It also analyzes the National Transportation Safety Board, the party responsible for independently investigating the accident and recommending following steps. For systems like public transportation, safety should be the primary concern, and any ethical framework that is incompatible with safety has no place in public transportation.

Metro Crash[edit | edit source]

Fort Totten is part of the Red Line Washington Metro in Washington, D.C. At 4:57 PM EDT, Train 112 left the Takoma station for the Fort Totten station. Train 214 was stopped completely right before the Fort Totten station while waiting for another train to leave the station. At 5:02 PM EDT, train 112 rear-ended train 214, killing 9 people, including the operator of train 112. This crash is the deadliest accident in Metro history. Emergency brakes were applied by train 112 but it was too late to avoid collision. Train 112 telescoped train 214, causing the doors of the rear car to not open. Rescue workers required ladders to access the rear train and rescue trapped passengers. The cause of the crash was traced to a faulty circuit that train 214 was stopped on, making it effectively invisible to the train control system. Because train 214 was not visible to the train control system, train 112 traveled at full speed as if there were no trains in front of it.

Issues ignored[edit | edit source]

2 near-collisions in 2005 were a result of faulty track circuits creating false signals which was the same failure in the Ft. Totten crash. Archived Metro data shows the track circuit had this issue since 1988, and Metro issued a technical bulletin outlining an enhanced circuit testing procedure to address the issue but no technicians were aware of it prior to the 2009 accident. Also, the track circuit manufacturer never provided a maintenance plan that would detect anomalies in the track circuit which would have given technicians the ability to identify and fix the bad track circuit and prevent this disaster. Also, Metro’s chief safety officer lacked the necessary authority and resources to adequately address system safety issues.[1]

Train controllers monitor computer-generated displays of track circuits. Controllers are responsible for regulating traffic flow and would have no warning that a train collision was about to occur because only the automatic train control system can maintain train separation. The automatic train control software detects patterns in track occupancy and displays its results to the controller. Faulty track circuits including the one that caused the Fort Totten incident report as occupied without a train present due to software design flaws and malfunctioning track sensors. These types of errors are classified as minor alarms that are ignored by controllers. Also, errors where track circuits are wrongly reporting as vacant with a train present are considered minor errors and are ignored as well. These two types of errors occur about 8,000 times per week according to archived Metro data.

Previous trains earlier in the day passing over the faulty track circuit triggered these minor alarms that were ignored by the control center operators and software. These trains had enough momentum to reach the next track circuit down the line to continue receiving speed commands. Train 214 was being operated in manual mode and was traveling slower than the automated speed commands which caused it to stop on the faulty track circuit which made it invisible to the software and controllers. ATC software recognizes the disappearance of train 214 as a false train indication and removes train 214 from the display and sends speed commands to train 112.

National Transportation Safety Board[edit | edit source]

The National Transportation Safety Board (NTSB) is an independent watchdog agency that explores the root cause for transportation accidents. As an independent federal agency, it is the NTSB’s role to determine the root cause of any aviation, highway, marine, pipeline, and railway accident. A concluding investigation involves recommendations that the parties involved should follow to reduce the chance of further accidents. The NTSB has no ability to set policy or enforce its recommendations. It is up to the involved party to decide whether or not the recommendations are followed. This is in contrast with other federal watchdog agencies, like the Occupational Safety and Health Administration (OSHA). This agency ensures worker safety in the United States, and they have the responsibility to create and enforce safety standards for industry. They can give citations to companies that do not comply to their code.

The NTSB publicly lists its safety recommendations and their outcomes for the last sixty years. This data contains information about the accident, the parties involved, the recommendations given, and whether or not they were followed through properly. The recommendations can be simplified to acceptable or unacceptable responses. From 1960 to 2019, approximately 81% of responses have been acceptable. Reducing the timeline to analyze the data post Fort Totten Metro Crash, from 2009 to 2019 about 84% of recommendations have acceptable outcomes. While this data does not aim to prove that the Fort Totten Metro Crash made groups more likely to follow NTSB recommendations, it suggests that the ignored warnings as shown by the WMATA are analogized nationwide. Further research could implore the connection between ignored safety recommendations and the probability of future accidents.

Even though the NTSB does not have the power to enforce its recommendations, it is still highly respected across industries. A medical journal suggested using the NTSB's safety recommendations in reproductive medicine due to the analogies between the aviation and reproductive medicine industries.[2] Both the aviation industry and reproductive medicine have low probabilities of catastrophic errors. This paper states that it is therefore imperative to have an independent board to review national cases of errors and give recommendations, so that doctors that have never experienced these situations can learn from others.

Conclusion[edit | edit source]

The Fort Totten metro crash was a tragic accident that many people hoped would not repeat again, but a similar incident happened only 6 years later at the next station. In January 12, 2015 the train, which just left the L'Enfant Plaza station, came to a halt in the middle of the tunnel because of an electrical arcing event occurring about 1,100 feet ahead of the train. The tunnel was full of smoke due to arcing and the smoke quickly filled in the train that was stopped in the middle of the tunnel. Due to this incident, 1 passenger died and 91 people were injured, 89 of whom suffered smoke inhalation. The 2015 accident is similar to Fort Totten metro crash because it was a preventable accident. The warnings from the NTSB have been repeatedly ignored over the years and lead up to this incident. After the death of 9 people from the metro crash in 2009, officials were expected to have learned the lesson to take warnings from NTSB seriously but not much has changed. Though NTSB does not have power to enforce the recommendations, metro officials should consider them attentively to prevent future accidents.

Recommendations[edit | edit source]

The Fort Totten Metro Crash investigations involved the WMATA and the NTSB. While this article goes details the NTSB, further research could analogize the WMATA to other railway assocations, or perhaps other public transportation organizations. Additionally the data from the NTSB website could be expanded upon for further inquiry.

References[edit | edit source]

  1. https://www.ntsb.gov/investigations/AccidentReports/Reports/RAR1002.pdf
  2. Scott, Richard T. and Ziegler, Nathalie De (2013). Could safety boards provide a valuable tool to enhance the safety of reproductive medicine? Fertility and Sterility