The commission was later told, and saw evidence, that at the direction of a supervisor, a bolt had been tightened on the coupler assemblies, the panel said. “This is not the first time we’ve identified issues with the chain of custody of evidence or inappropriate handling of evidence related to Metrorail safety events,” commission Chief Executive David L. Mayer said in a meeting of the panel.
Mayer was referring to a commission audit issued last month, which among its conclusions, said Metro’s culture is such that the agency cannot be trusted to investigate incidents.
The audit, of the system’s rail operations center, cited “unprofessional behavior such as attempts to manipulate safety event investigations that create unacceptable safety risks.” It said that manipulation extended to the safety commission’s audit as managers tried to shape what information workers disclosed to auditors.
The most recent incident involved an investigation into an Oct. 9 incident in which two cars on a Red Line train separated suddenly, stranding more than 100 riders on a track in downtown Washington for more than an hour.
No one was hurt in the incident, and all 108 passengers were escorted off the train safely. However, two passengers were treated on the scene after complaining of chest pains or shortness of breath.
The eight-car train was leaving Union Station toward NoMa-Gallaudet when the first two cars and the last six separated.
The commission issued a corrective action plan Tuesday directing Metro to comply with its own investigation procedures.
“We issued today’s finding to require Metrorail to comply with its investigation procedures and to maintain the integrity of each investigation,” the commission’s chairman, Christopher Hart, said in a statement to The Washington Post. “This is to ensure that the right lessons are learned, and safety improvements are made to reduce the risk of similar events occurring in the future.”
Metro Chief Safety Officer Theresa M. Impastato said the maintenance workers who manipulated the bolt did not have “nefarious intent” but were testing bolt torquing for Metro’s own investigation. Proof of that, she said, was that the workers reported the results of their tests to their supervisor before safety investigators arrived.
“In response, Metro is updating accident investigation policies so that every employee understands the roles, responsibilities and requirements during a safety investigation,” Impastato said in a statement.
Metro Board Chairman Paul C. Smedberg said he could not comment specifically on the allegation because the uncoupling remains under investigation. But he said board members are expecting an update from Metro General Manager Paul J. Wiedefeld and Impastato at Thursday’s board meeting.
“We welcome the [the safety commission’s] recommended corrective action as opportunity to improve rail safety event investigations,” Smedberg said in a statement.
The incident provided another footnote to critics’ long-held belief that the transit agency does not learn from its mistakes. Tuesday’s was about the 70th order for corrective action that the safety commission has issued to Metro since the commission’s inception two years ago.
The cars involved in the separation were moved to the Brentwood Rail Yard, where investigators from the Metro safety department made an initial examination. The coupler assemblies, which connect the cars, were moved to the Greenbelt Rail Yard repair and overhaul center.
The next day, when Metro and safety commission investigators arrived to evaluate the assemblies, they found that the equipment had been manipulated, the commission said.
Inspectors saw evidence that the torque stripe on a bolt had moved clockwise, indicating that the bolt had been tightened, according to the commission’s findings. They learned that the tightening was done on the orders of a supervisor.
“Our review of the couplers assembly the morning after the train pulled apart demonstrated that Metro had not followed its own investigative procedures regarding the chain of custody for evidence,” Mayer said. “A Bolt clearly had been torqued after the event without communication with and approval from Metro’s Safety Department and the [safety commission].”
Mayer said a “torque check” was done the night before without approval from Metro’s safety department and the safety commission, as Metro’s operating procedures require.
He cited other examples of Metro workers manipulating evidence. After an Aug. 15, 2019, collision of trains stored at Largo Town Center, the commission said in its findings that a train operator tried to “decouple” the wreck without permission, “thereby disturbing the scene.”
A safety commission audit released last month found 21 major safety issues or violations including how Metro handled evidence after incidents.
The audit said Metro had no guidelines or policies barring the editing or deleting of raw data from audio or video files before they are sent to investigators. There also was no independent chain of custody for evidence, allowing access to those who might be involved or connected to actual incidents. The audit also called on Metro to record and preserve phone calls, ambient conversations and other communications during emergencies.
In the case of the torqued bolt, Mayer said, a manager directed employees to conduct testing without regard to Metro’s standard operating procedures for investigations.
“This concern crosses all aspects of Metrorail,” he said.
During a briefing about a Feb. 4 fire that took place near one of the tracks, Hart said it appeared that Metro was not using the word “smoke” in describing events as he thought officials should.
“I noticed the place where it looked like the word smoke was not used when it should have been, and I just wonder, did you have any sense that the word smoke generates a need to follow different specific procedures that they wanted to avoid so they didn’t use the word smoke? Did you get any sense of that?” Hart asked a commission staff member.
“There has been a habit of either leaving out smoke or using other phrases that we have addressed our concerns with [Metro] and the safety department,” Adam Quigley, a program specialist, responded.
Metro was given 30 days to start “initial and ongoing refresher training” on following proper chain-of-custody procedures, keeping control of evidence and being forthright in providing investigators with direct access to recordings and other potentially relevant information, according to the commission’s findings.
“These examples demonstrate that from the front line worker involved in a safety event up to the level of department leaders, Metrorail employees are not properly trained on and familiarized with their basic responsibilities related to safety event investigations,” the safety commission report said.
October 21, 2020 at 06:22AM
https://www.washingtonpost.com/local/trafficandcommuting/metro-tampered-with-evidence-from-red-line-decoupling-incident-safety-commission-says/2020/10/20/502d0cee-12ec-11eb-ad6f-36c93e6e94fb_story.html
Metro tampered with evidence from Red Line decoupling incident, safety commission says - The Washington Post
https://news.google.com/search?q=Red&hl=en-US&gl=US&ceid=US:en
No comments:
Post a Comment