By Kim Smiley
On September 30, 2015, the National Transportation Safety Board (NTSB) issued urgent safety recommendations calling for the Federal Railroad Administration to take over the task of overseeing the Washington, DC Metro system. The NTSB has determined that the body presently charged with overseeing it (the Tri-State Oversight Committee) doesn’t provide adequate independent safety oversight. Specifically, the Tri-State Oversight Committee doesn’t have the regulatory power to issue orders or levy fines and lacks enforcement authority.
The recommendations resulted from findings from the ongoing investigation into a smoke and electrical arcing accident in a Metro tunnel that killed one passenger and sent 86 others to the hospital. (To learn more, read our previous blog “Passengers trapped in smoke-filled metro train”.) The severity of damage done to the components involved in the arcing incident have made it difficult to identify exactly what caused the arcing to occur, but the investigation uncovered problems with other electrical connections in the system that could potentially lead to similar issues if not fixed.
Investigators found that some electrical connections are at risk of short circuiting because moisture and contaminants may get into them because they were improperly constructed and/or installed. The issues with the electrical components were not identified prior to this investigation which raises more questions about the Metro’s inspection and maintenance programs. Although the final report on the incident has not been completed, the NTSB issued recommendations in June to address these electrical short circuit hazards because they required “immediate action” to ensure safety.
Investigators have found other issues with the aging DC Metro system such as leaks allowing significant water into the tunnels, issues with inadequate ventilation and questions about the adequacy of staff training. The final report into the deadly arcing incident will include recommendations that go far beyond fixing one electrical issue on one run of track.
This example is a great illustration of how digging into the details of one specific problem will often reveal information about how to improve reliability across an organization. It may seem overwhelming to tackle organization-wide improvements, but often the best way to start is with an investigation into one issue and digging down into the details.