When will someone finally address what really killed Carol Glover?

For more than a month politicians and reporters have failed to address the most important issue surrounding the death of Carol Glover and the injuries of more than 80 others after smoke filled a Yellow Line Metro tunnel in Washington, DC on January 12. Since Glover’s death, the headlines and soundbites have focused mostly on radio interoperability, broken fans and Metro’s deteriorating infrastructure. Even today, The Washington Post writes about problems with the software that controls key functions in the subway system.

DC Carol Glover
Family photo of Carol Glover

Most, but not all, of the items mentioned are legitimate issues that need to be addressed. But, despite evidence that’s been in their hands for many days, no elected official or news organization is focusing on what really killed Carol Glover.

The answer can be found in the official documents from both the National Transportation Safety Board (NTSB) and the Homeland Security and Emergency Management Agency (HSEMA) for the District of Columbia.  But everyone seems to miss the fact that it isn’t hardware or software that failed Carol Glover and the other passengers fighting for their lives on January 12. This is a people problem.

OCC & OUC

I’m referring to the people who work in two key centers greatly responsible for the emergency response on January 12. These employees of both Metro and the DC government have proved over and over again they just don’t know what to do when there’s an emergency. In addition, they are managed by people who continually show they don’t understand the importance of sending Metro passengers away from a hazardous situation while immediately alerting  fire and EMS to respond.

To be more specific, Carol Glover died because, despite clear warnings there was a smoke issue, Metro’s Operations Control Center (OCC) sent two trains full of passengers toward trouble. They also waited 18 minutes before calling firefighters to the scene. That delay — in getting help to Ms. Glover and the other passengers — continued even after OCC finally contacted DC’s Office of Unified Communications (OUC or 911 center). OUC took an additional six minutes to alert firefighters and apparently failed to give those firefighters all the information they knew about the emergency.

WE’VE HEARD ALL OF THIS BEFORE

Unfortunately this ineptness at both OCC and OUC is nothing new. These very same failures have been documented during previous emergencies going back many years.

As STATter911.com first told you on January 12, Metro’s OCC also sent trains toward smoke and fire in a very similar incident on April 20, 2000 when the third rail belched fire and smoke at the Foggy Bottom station. Despite more than 270 people trapped, OCC waited 15 minutes before calling for firefighters (more about the 2000 incident here and here).

They waited 12 minutes to call for help after a January 2007 derailment that injured 20 passengers at Mt. Vernon Square. There was a 19 minute gap after a June 2008 derailment in Arlington (read more about OCC delays here).

Metro was a little better during its first fatal crash. They only waited four minutes before calling for help when a derailment killed three passengers on January 13, 1982 (thanks to Roger Bowles of Discovery Performance Analysis, LLC for sending a copy of the NTSB report).

As for DC’s problem-plagued 911 center, I documented a February 2007 incident where OUC waited 10 minutes before dispatching firefighters to a report of a fire at Metro’s Farragut North Station (more stories from OUC’s long record of poor service here & here).

History repeats itself when it comes to OCC and OUC because no one in charge at the Washington Metropolitan Area Transit Authority (WMATA) or the government of the District of Columbia thinks properly training workers on simple, common sense emergency procedures is very important. Maybe that’s because both local politicians and members of Congress have never made this a priority. Since January 12, elected officials have talked about everything but the abysmal handling of this emergency by workers at OCC and OUC.

DC City council hearing on MEtro 1 2-6-15

THE HEARINGS MISSED THE OBVIOUS

Members of the DC City Council had the director of the 911 center right in front of them at the witness table on February 6 and never questioned Jennifer Greene on anything of substance involving the January 12 incident. They failed to question Greene about OUC’s poor performance that day even though the details were already public in three separate reports from the DC government on January 15January 17 and January 23. (To further understand the depth of the problem at OUC make sure you read the transcripts starting on page 29 showing how some of the 911 calls were handled. You can listen to two of the calls here and here.)

The House Subcommittee on Government Operations spent much of its Metro hearing last Friday (video above) focusing on radio interoperability. Radio interoperability had zero relevance to anything that occurred January 12. Members of Congress at the hearing all but completely ignored details on the bad decisions and delays by Metro’s OCC that were revealed just two days earlier by the National Transportation Safety Board (NTSB). (To be fair, they did talk about the poor handling of ventilation fans that enveloped the stranded train in smoke instead of drawing it way from the train. It’s a key issue and also another people and training problem at OCC.)

THE KEY IS THE TIMELINE

What our elected officials and news organizations have failed to address is easily found in the timeline of the incident. It clearly shows January 12 should have just been another day of delays on Metro rather than a day of death and injury. NTSB and DC have provided enough times that show the key actions at both OCC and OUC.:

  • 3:04 p.m. First sign of trouble when a smoke alarm sounded at a vent shaft in the tunnel near L’Enfant Plaza. Despite this warning, Metro’s OCC didn’t stop other trains heading in this direction and did not call for firefighters.
  • 3:15 p.m. Train 302 stopped in the tunnel after encountering heavy smoke upon leaving the L’Enfant Plaza station heading toward Virginia. OCC didn’t stop other trains heading in this direction and did not call for firefighters.
  • 3:19 p.m. A second smoke alarm activated. OCC didn’t stop other trains heading in this direction and did not call for firefighters.
  • 3:20 p.m. A third smoke alarm activated. OCC didn’t stop other trains heading in this direction and did not call for firefighters.
  • 3:22 p.m. Train 510 pulled up to the platform at the L’Enfant Plaza station, exposing the passengers to the smoke conditions now apparent in the station. It was only then that Metro’s OCC contacted DC’s OUC asking for firefighters from the DC Fire and EMS Department to respond to L’Enfant Plaza.
  • 3:28 p.m. DC’s OUC finally dispatched the DC Fire and EMS Department to L’Enfant Plaza. Handling such a call at a 911 center should only take about 90 seconds. DC’s OUC needed approximately six minutes. (Note: DC’s OUC received calls for two different locations prior to receiving the L’Enfant Plaza information. It took five minutes to dispatch one of those calls and four minutes for the other. These call handling times are a key indication of the level of dysfunction at the 911 center in our Nation’s Capital.)

DC Carol Glover 2

THIS IS WHAT KILLED CAROL GLOVER

Figuring out what happened here isn’t very difficult. What started as a simple act of ignoring the warning of a smoke alarm turned deadly.  If Metro’s OCC immediately halted trains heading towards that sounding alarm and/or both OCC and OUC got firefighters out the door much earlier, it would have avoided almost all of the other problems everyone has been talking about since January 12.

Sending two trains loaded with passengers into a known trouble area and delaying the fire and EMS response by more than 20 minutes is what killed Carol Glover.

Poorly trained people lead by inept management destroyed one life and put the lives of hundreds of others in jeopardy. If those in charge don’t finally focus on this sad fact, this scenario will play out the very same way the next time a smoke alarm sounds in a Metro tunnel.