An early investigation has indicated that a technology failure contributed to the recent Metro crash that killed nine and injured scores:
A senior Metro official knowledgeable about train operations said an internal report confirmed that the train control system failed to detect the idling train when the crash occurred about 5 p.m. on a curved section of track between the Fort Totten and Takoma stations.
Metro has temporarily reassigned the top official in charge of the train control systems that are supposed to prevent crashes. Matthew L. Matyuf, superintendent of the Automatic Train Control Division, has been assigned to a “special project,” spokeswoman Lisa Farbstein said yesterday.
…where “special project” = something unrelated to investigating his division’s presumed failure. It is noteworthy that the tests replicated the conditions and malfunction presumed responsible for the crash, and telling that NTSB was not prepared to state definitively that the malfunction caused the crash. Saying so would likely prejudice the inevitable legal proceedings.
Some questions naturally fall out of this test, most of them fairly obvious:
- Why did this not happen before?
- Why did testing not identify this as a critical risk (if it didn’t)?
- Where else might this problem surface within the system?
- Are the newer-model trains definitively immune to the malfunction?
- Are there other identifiable malfunctions?
- Who signed off on the design, and based on what criteria?
- What trade-offs has Metro made because of funding?
- Was this malfunction a known problem?
With apologies to my many friends in DC who take Metro daily (and, it should be noted, without incident), the accident casts a shadow of doubt on the integrity of the system. That doubt may not be justified given the safety record of the system as a whole, but it is there and must be addressed.
In my writing and teaching, the same three factors are invariably cited as causes of failure in projects and systems: poor communication, lack of clear objectives, and absence of senior leadership support. It isn’t always all three that are at fault, but one almost always shows up. It’s a well-worn trope here at the blog, but like 9/11, the space shuttle, and any number of other postmortems, one would hope that an organizational analysis accompanies systems findings. The root causes almost certainly lay there.