Rebuilding Place in the Urban Space

"A community’s physical form, rather than its land uses, is its most intrinsic and enduring characteristic." [Katz, EPA] This blog focuses on place and placemaking and all that makes it work--historic preservation, urban design, transportation, asset-based community development, arts & cultural development, commercial district revitalization, tourism & destination development, and quality of life advocacy--along with doses of civic engagement and good governance watchdogging.

Wednesday, January 14, 2015

WMATA tunnel incident (and implications for agency leadership)

Also see "St. Louis regional transit planning process as a model for what needs to be done in the DC Metropolitan region" from 2009.

In response to a piece about the incident earlier in the week as discussed in the City Paper, here is my response:

The 1000 series car didn't create the smoke and so is nonmaterial/coincidental. The issue is (electrical) fire and smoke.

Smoke inhalation is dangerous. People can and in this case, did, die from it. Therefore, standard operating procedure should be to not leave a train and its passengers sitting in a tunnel for any significant length of time when the tunnel is filled with smoke.

If you leave people in a train tunnel where there is a great deal of smoke, their ability to breathe will be affected. So you either back up or you let out the riders onto the tracks so they can walk out of and evade the area of the incident. Neither course of action occurred in a timely manner.

You don't really need a big NTSB investigation to draw the right conclusions on what should have happened ... and the NTSB investigation will make 6/7 conclusions:

(1) it's bad for riders to be in a position where they are forced to breathe in and inhale smoke.

(2) therefore, it's bad to leave a train sitting in a tunnel filled with smoke.

(3) WMATA overarching train operations leadership failed to give proper instructions to the train operator to remove the train and/or passengers from this dangerous situation.

(4) it would have required acting without orders/against instructions, but the train operator could have taken his own initiative to move the train backwards out of the tunnel (e.g., see #1).

(5) baring that, the train operator could have gone through the train and opened doors so riders could leave the car to walk out of the tunnel to safety (e.g., see #1)

(6) the fire department did not respond and act in a timely and expeditious matter

(7) WMATA operations personnel and management lack the initiative and ability to respond to and deal with immediate crisis in a manner which enhances safety and reduces the severity of problems and WMATA should deal with this from a process redesign and training standpoint.

1979 NTSB report on a train fire in the Transbay Tunnel of the BART system in San Francisco has a few conclusions: (1) the failure of BART to quickly coordinate with the local fire departments; (2) not following its emergency plans; (3) and that "The cause of the fatality and injuries was the inhalation of smoke and toxic fumes..."


"Revise emergency procedures to clarify the necessity of unloading the passengers immediately from a stopped burning train in the Transbay Tunnel and other long tunnel locations"

"Revise Transbay Tube emergency fan and damper procedures to prevent smoke from engulfing an entire train..."

For what it's worth, my point #7 is key.  That's why incidents such as this continue to occur.

For what it's worth/2, NBC4 ("Metro Appoints Jack Requa as New Interim General Manager") and other outlets list potential replacements for Richard Sarles, who is stepping down as the head of the agency.

This week's incident is an example of why people highly knowledgeable in transit/transit operations should lead the agency, which ought to ding Allen Lew as potential leader of the agency, and probably should disqualify Rob Troup, currently Deputy General Manager of Operations, since the Metrorail division continues to demonstrate significant operational problems.  Although since Mr. Troup has only been with the agency for four years, maybe he can argue he is the right person to right the ship.

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At 8:41 AM, Anonymous h st ll said...

Excellent summary/piece. We need you to lead WMATA though!

At 9:00 AM, Blogger Richard Layman said...

one time I did apply for a communications job there and I never got a response. (It was awhile ago.)

DK if you ever read Andromeda Strain. There is a discussion of the thesis of "the odd man out" being necessary in high functioning teams, to guard against group think.

My experience is that this thesis isn't regularly applied in govt.

But thanks for the vote of confidence!

At 1:11 PM, Anonymous Anonymous said...

sadly, there is a culture of intransigence and lassitude in metro. there seems to be little concern about communication to passengers when critical situations arise- half of the time the damn speakers are not easy to hear and are either non functioning or blaring to the point of incomprehension. I also believe that there is certainly a fear to act because of liability problems- this constrains operators who might otherwise take the initiaive. As it stands presently- it is a bureaucracy that stifles initiative to the utmost. Anyone who actually does try to help would be scorned or shot down in this atmosphere.

At 1:28 PM, Anonymous charlie said...

I'm not sure any change of executive leadership can make a a difference.

We are talking about crippling levels of incompetence The escalators not being serviced, the entire signalling system being installed incorrectly, and now they don't even have a protocol for getting people out of a tunnel.

And the real problem goes to governance. I don't blame MB for the weak response by DCFD. I do blame her from her years of sleeping through WMATA board meetings. The only real function of the board is to get buy in for jurdictional subsidies.

At 2:09 PM, Blogger Richard Layman said...

good comments. And again, charlie you have a gift for the succinct sum up in your last sentence.

Actually, I do not blame MB for the DCFEMS response, but clearly the response was substandard and not SOP, just like Metrorail's response.

Both agencies are stifled, as anon@1:11 makes clear.

At 2:32 PM, Anonymous charlie said...

" response was substandard"

Are we sure? As far I can tell DCFEMS likes to run around with their lights and sirens on, but if confronted with an actual emergency (the elderly gentleman who was mugged who they thought was drunk, another incident on RI, or smoke in a metro tunnel) their SOP seems to be sit back and wait for someone to die.

Again, not MB fault, although it will be her fault if she can't clean house after this.

At 8:33 AM, Anonymous Anonymous said...

as I see it- all metro board members should be REQUIRED to use metro and to be car-free households.

At 10:33 AM, Blogger Richard Layman said...

charlie -- brutal...

At 1:21 PM, Anonymous charlie said...

Brutal? IT is the truth. That entire department needs to be rooted out.

And t a minimum Fire and EMS need to separated.

I have a nice few of a disabled housing on 13th. At least two ambulances a day. People use them like Uber, at $1000 a pop.

I'd hazard that 75% of truck runs could be replaced.

At 3:09 PM, Blogger Richard Layman said...

one of my pieces on this subject starts out with my response to someone asking about this, something like "if the fire trucks didn't go out on EMS calls, they'd never leave the station."

But yes, Seattle's Medic One is probably the model of how to rethink the service.

... you probably aren't old enough to have watched the tv show "Emergency." I loved it when I was a kid...

At 4:55 PM, Anonymous Anonymous said...

The Federation of Citizens Associations under the unrelenting efforts of George Clark and Anne Renshaw kept the pressure on after the tragic assault and death of NY Times journalist David Rosenbaum.

Charlie is spot on regarding DC FEMS being the Uber of the disability set. The statistics at the time bore this out and probably still do. Perhaps it's time for the Rosenbaum children to join with the family of this latest victim (or victims) and finally force reform on this dysfunctional agency.


At 8:12 PM, Blogger Richard Layman said...

my friend Dan Wolkoff is a bit out there. He is apoplectic about sirens because he seems to be hyper aware of them and he lives a couple houses down from 12th and 13th Streets NE, which are routes for emergency vehicles going to Providence Hospital.

He says one of the problems of the vehicles always running with sirens is that it hypes up the personnel. But most of the time they end up dealing with drunks. So they end up coming to believe that everyone needing service is a drunk.

... which is why they "misdiagnosed" David Rosenbaum.

I think Dan was right...

At 9:02 PM, Anonymous Anonymous said...

The siren thing may have added to the incompetent diagnosis but that is not the point.

There was a "cascade of errors" in the Rosenbaum case, every step of the way including FEMS (misdiagnosis, lollygagging and wrong hospital), the hospital (which twice misdiagnosed him and didn't operate on him for seven hours) and finally the failure of MPD which could have hauled the attackers off the streets had it done its job and investigated a 2005 attack.
Keystone Kops... and I would be shocked if much has changed.


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