Tuesday, May 16, 2006

Metro Fatality: Did Worker Just Neglect His Training?

Washington Metro employee Jong Won Lee, 49, was killed Sunday after being hit by a Metro train while repairing track equipment. Today, the Washington Post greets us with this headline:
Worker Hit by Train Took Safety Course

The Metro employee who was struck and killed by a train Sunday at the Dupont Circle Station had received extra safety training put in place after a similar workplace fatality seven months ago, an agency spokeswoman said yesterday.
Well, shit, if he had "extra safety training," clearly he must have screwed up and disregarded his "extra safety training," right? Case closed.

Not so fast. First, it's far too early to tell. But from what we know about this accident, and a similar Metro fatality seven months ago, it isn't clear that even "extra, extra, extra training" would have helped.

What do we know so far?
Trains were running in both directions. The employees were able to stay clear of a northbound train. But Lee, who had worked for Metro since 1999, stepped back to avoid that train and was hit by a southbound train, No. 110, Metro officials said. He was struck, knocked onto the 750-volt third rail and electrocuted, according to Metro spokeswoman Lisa Farbstein. The third rail powers the trains and runs parallel to the rails that carry them.

The train that struck Lee was operating in automatic mode, traveling at 40 mph and braking as it entered the Dupont Circle Station, she said.
And what do we know about the previous fatality the resulted in the "extra safety training?" According to a Metro press release
"Various safety procedures were not followed during the track work project," said Fred Goodine, assistant general manager for system safety and risk protection. "For example, the track and structures and systems maintenance supervisor failed to contact the operations control center before approaching the track work area. He later left the work area, failing to ensure a safe work site for the crew at the time of the accident."

Also, train operators are supposed to sound a horn to warn track workers the train is approaching and stop if they don't receive acknowledgment that it was heard. The panel ruled that two train operators, including the one that hit Waldron, did not follow those procedures.

"Those operators will be disciplined for not following those procedures," said Steve Feil, chief operating officer of rail. "But the main fault still lies with the dismissed supervisor for not notifying his crew of the oncoming train or the operations control center of their location."

***

"This is a sad time for us. Had employees followed proper procedures, this unfortunate accident wouldn't have happened," Goodine said.
OK, let's first note the fact that the focus of that investigation was on the supervisors and the train operators, not what the worker who was killed did or what kind of training he had or didn't have.

But more important, although I haven't seen that report, but I'm always very suspicious of any accident investigation that concludes that "human error" was the main cause. As we've seen numerous times, most notably in last year's BP Texas City refinery explosion that killed 15 workers, it's too easy -- and generally wrong -- to simply blame workers for not following procedures and then fire the wrongdoers.

Usually, if you look a little deeper and ask "why" the workers weren't following procedures, you'll find the real root causes which, if corrected, could prevent similar accidents as well.

The fact is that human beings inevitably make errors. In fact, errors should be expected. But rather than focusing on the workers who make the errors, effective accident analysis – analysis that actually wants to get to the root causes and effective solutions -- looks for the conditions that made the errors possible.

Why weren't workers following procedures? Were they told to do things a different way by a supervisor who had a quota to fill? Were employees expected to take shortcuts to get the work done faster? Did they feel rushed by the constant drive to finish a job by the deadline? Were they not well trained for the job? Were they tired from too much overtime? Did the written procedures not make sense in the environment in which they were working? Did they not have the proper tools? These are the kinds of questions that need to be asked. Because if the answers to any of these questions lead to the real root cause of the accident, just firing someone isn't going to help anything. The same conditions are still there, and the same accident will happen again.

So here's a hint for Metro investigators. When you have two similar "human error" accidents, most knowledgeable investigators will tell you that it's a pretty good sign that you missed some of the deeper root causes in your first investigation.

Finally, maybe the answer to this problem is obvious. You can do extra, extra, extra super-duper training and fire everyone who even thinks about violating procedures. But ultimately, it may just come down to this: Maybe it's just too dangerous to have workers on the tracks when trains are traveling in both directions.


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