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Communication breakdowns undercut response in deadly Metro incident

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June 27, 2015 at 9:09 p.m. EDT

It was raining Jan. 12 at L’Enfant Plaza when a Metro Transit Police official walked over to a District fire official’s SUV.

A tunnel below L’Enfant Plaza was filling with smoke, and a train was stuck in the tunnel. Metro’s deputy police chief, Mark Olson, wanted to elevate command of the incident to D.C. Fire Capt. Lawrence Chapman.

It was not a smooth handoff.

Their difficult exchange is one of several communications issues and breakdowns under scrutiny by the National Transportation Safety Board as it investigates the cause and response to the smoke incident that killed one passenger and injured scores of others in the Yellow Line tunnel.

The NTSB held hearings and released thousands of pages of investigative documents last week as part of its probe. The transfer of authority between Metro and the Fire Department was captured in interviews and underscores the communication issues.

WMATA surveillance video inside L’Enfant Plaza Metro station on Jan. 12, 2015, shows people on the platform evacuating. (Video: NTSB)

Relentless grilling of Metro over L’Enfant tunnel incident

Olson recalled saying, “We have a train trapped down there with patrons on board and I’m very concerned about a self-evacuation. We need to get evacuation of those patrons started immediately,” according to the documents released by the board.

Chapman, Olson said, “looked over at his driver and then he said something to the effect of, ‘Well, I have to get my personnel down there to assess where the smoke’s coming from first.’ I again stated to him, I said, ‘We have passengers on that train that we need to get evacuated.’ He rolled up his window.”

Olson told investigators that he felt it was a “shunning.”

Chapman, the documents show, had a different account. He remembered being told “ ‘Well, we have an unknown fire somewhere; it’s creating this smoke condition.’ At this point, I’m starting to realize that they have a train stopped in the tunnel. Now we’re talking about this train car and he said, ‘Well, there’s people on it and we would like to try and move it back to the station.’ ”

Chapman said his mind turned to the power line in the tunnel where his crews were headed. And he wasn’t certain that Metro understood the status of its own train and “whether it could be moved or not.”

Safety investigators did not ask Chapman whether he rolled up his window. But Chapman said that “you can imagine that the environment is a little tricky to work under. And at times I just have to sort of shut down and say, okay, I have to concentrate on what’s going on right here, right now. And I think that can be taken the wrong way, shall we say?”

The investigation into the deadly Jan. 12 smoke incident near L’Enfant Plaza Metro station is still underway. Wednesday's National Transportation Safety Board hearing centered on employees' comfort with reporting safety concerns. (Video: WUSA9)

Far from shunning, Chapman said he thought the agencies at the scene were “cooperating” and said that “if they had trouble communicating with me, I really wasn’t aware of it.”

During the two days of hearings last week, NTSB officials seemed incredulous at first responders’ inability to communicate, let alone cooperate.

“Is there any equipment or any reason why [Olson] could not have gotten into the back of the vehicle, because it’s pouring down rain?” said Robert Sumwalt, an NTSB board member. He was told that yes, with a little effort, there should have been a seat available for him.

Sumwalt also pointed to a broader lack of coordination — among Metro train controllers sitting in their suburban Maryland operations center, and between those controllers and people on the scene. “I want to know who the heck’s in charge,” Sumwalt said.

The answer?

Different people were in charge at different points as the crisis escalated and demanded more attention and a widening emergency response. Yet when it was their turn to take the lead, several people in authority made decisions that did not improve, and may have worsened, circumstances for passengers aboard Train 302, interviews and records released by the NTSB show.

What the Metro train operator heard in the tunnel: Yelling, kicking, screaming and banging.

Train 302 came to a halt after encountering smoke in the tunnel and asked Metro operations officials for permission to reverse direction and go back to L’Enfant Plaza, NTSB exhibits show. That plan was thwarted, however, when a second train entered the station and, with smoke building, Metro Transit police evacuated passengers and the second operator, leaving an empty train on the platform. Metro rail controllers persisted in planning to reverse Train 302 to the station, unaware that Metro Transit Police had removed the second operator from the station, according to interviews.

The 6,000 pages of documents made public by NTSB last week include interviews with senior Metro executives whose responsibilities include systemwide safety, power systems, emergency ventilation, maintenance and control of rail operations — all areas that have emerged as likely factors in the disaster.

The NTSB investigation is ongoing and has yet to determine the probable cause of the accident in a tunnel south of the L’Enfant Plaza Station.

Broader fire presence

The January incident has prompted Metro to enhance its Rail Operations Control Center (ROCC) in Landover — the system’s nerve center — by agreeing to host a fire official in the room on most days, not only during emergencies. Currently, the District or Prince George’s County sends fire officials to the ROCC when there is an incident.

Fire departments have lobbied for a broader presence for years. The goal is a 24/7 position, though for now it will be 40 hours a week when it launches Monday, with Metro covering the cost. Beyond immediate crises, the on-duty fire official will also use the time to help improve training for controllers on emergency command and control issues.

The agreement followed a post-accident push by Sens. Mark R. Warner (D-Va.) and Barbara A. Mikulski (D-Md.), who were dismayed at inter-agency finger-pointing after the Jan. 12 catastrophe. The updated agreement covering emergency procedures, signed by Metro and a dozen Washington-area fire chiefs this month, also requires weekly or biweekly testing of Metrorail radios and more training for first responders.

Embedding an experienced fire official is intended to bridge a gulf that has grown for years between fire-rescue personnel and train controllers, who exert far-reaching authority over the subway.

"The controllers as they're called . . . they control the lines, control the movement of trains, control the signaling. They control the ventilation. They control the third-rail power. They are in direct communication with anyone and everyone working on board that particular line," Hercules Ballard, Metro's managing director for rail transportation and a former controller, said at the NTSB hearings.

Despite the breadth of their responsibilities, the normal workday in the ROCC is “relatively quiet,” Ballard said.

But there have been problems jumping from calm to crisis management. Fire officials from the region have long voiced concerns that ROCC employees sometimes lack the mind-set, experience and safety practices of their boots-on-the-ground counterparts.

There is also a well of distrust, emergency workers said, stemming from what they called Metro's inclination to try to handle seemingly small safety incidents in-house rather than immediately report them to 911 or fire-and-rescue departments. Firefighters worry that such lags could endanger passengers or rescuers. Metro says it has scores of fire or smoke incidents each year.

On Jan. 12, the District’s emergency call center first learned a train was stuck in a smoky tunnel not from Metro but a passenger who called 911, according to a timeline previously released by the city.

One problem is in the organization of the ROCC, said Marc S. Bashoor, fire chief in Prince George’s County. He headed a committee representing fire chiefs from the region in the recent agreement with Metro to add a fire slot into the ROCC.

When emergencies happen in a county including his, Bashoor said, there is a specific Emergency Operations Center set up to handle it. At the ROCC, he said, the emergency is added to the employees’ existing responsibilities to keep the rest of the train system running.

That occurred with controllers running the Yellow Line Jan. 12, who have told the NTSB that the tunnel incident was one of several unusual events they were juggling along with regular passenger service.

“I understand completely WMATA wants to continue, and they have to continue, providing service everywhere in the system,” Bashoor said. But, he said, fire chiefs expect that “when a disaster happens, there has to be a switch in the mode of operation.”

With the smoke incident at the L’Enfant Plaza station, “they were worried about all the other things going on with the system,” from making trains run on time to organizing buses to shuttle passengers stranded by the ongoing incident, Bashoor said.

"They're multi-tasking, doing a thousand things in the ROCC," Bashoor said, and a fire liaison would help the focus by being dedicated to dealing with 911. "That link . . . we believe is the key to, at a minimum, providing accurate and timely information we're not getting on a regular basis now."

And with better information, officials hope, there will be better decisions.

Olson, the deputy chief for the transit police at the scene Jan. 12, has retired from Metro. But in his late January interview with federal investigators, he was reflective, particularly on Metro’s relationship with District fire officials, which he said has had cycles of cooperation and strain.

“Had we known that January 12th this was going to happen, well, December 12th we would have been training very heavily with the D.C. Fire Department,” Olson said. “We’re probably as much to blame as they are as far as not insisting that there be more training, more contact with those folks that are going to be responding to these scenes and our folks who do respond to these scenes.”

marypat.flaherty@washpost.com