Two Screws

"For want of a nail the kingdom was lost."
-- from an old proverb

This writing started as a note to myself so I'm not certain about the date of the WTOP broadcast I mention in the second paragraph.  But my best guess is that it was January 18; in any event it was a few days after a smoke incident on Monday, January 12 in the subway system in Washington, DC that centered on the L'Enfant Plaza stop:

Just heard this at 1 PM on WTOP (the all-news radio station for the DMV -- District of Columbia and parts of Maryland and Virginia nearest the District):
 
When the emergency responders (fire and/or Metro employees) finally got to the trapped subway train, which was more than 40 minutes after thick black-orange smoke had filled the train cars, they ran into another problem.  The latches to open the emergency train doors from the outside weren't there.

Then the same responders found that the passengers trapped in the smoke-filled train couldn't open the emergency doors from the inside until two screws had been removed from the doors.  The report didn't say whether the screws were located inside or outside the train.
 
What's clear is that there's no mention of two screws and the need to remove them shown in the instructions posted in every train car for how passengers can open the emergency doors.

From the prominently displayed idiot-proofed written instructions and illustrations that accompany them, the process of opening the emergency exit doors from the inside is child's play.  Even the most panicked adult passenger could immediately comprehend how to open the doors from glancing at the large poster of instructions placed next to the emergency doors.
      
The missing outside door latches and the surprising existence of two screws are just one part of the mess involving Metro (the company that runs the subway trains), PEPCO (the electric company serving the subway system), the police, and the fire department.  A mess that cost one passenger her life and sent 85 passengers to emergency rooms, and most probably would have resulted in a train full of dead people if some passengers trapped on the train hadn't called 911 to report the situation and explain that several minutes had elapsed with no help arriving.

Reportedly, up until the passenger calls to 911, the fire and police departments had no idea how serious the situation was. They didn't know there were passengers trapped on a train in which smoke was being sucked in through air exchange vents. This, despite the fact that the billowing smoke had been noted by Metro almost as soon as it broke out in the L'Enfant Plaza station on the Yellow Line at approximately 3:15 PM -- must as the 'official' rush hour was getting underway in the nation's capital and throughout the Metro line.  (Because rush hour was just getting underway, if the smoke incident had started just a few moments later there would have been many more commuters trapped on the train.) 

Since I wrote the above, more of the story of what happened during the incident has been coming out, in dribs and drabs, from officials connected with various entities involved; e.g., fire department, Metro, etc. 
The incident is still under investigation -- a multi-agency investigation that could take a year before the final report is issued, according to one news report.  So exactly what happened, and who's to blame for what, is still shrouded in fog. But a couple days ago, I think it was, there was a news report on WTOP regarding an official announcement that investigators were currently looking at 10 lapses or issues that together led to the disaster and/or needed to be addressed to prevent another such disaster.

I note that the disaster wasn't the smoke incident itself, the cause of which is still being investigated -- although from an unconfirmed report it was due to electrical cable(s) falling on a section of the electrified 'third rail.'  The disaster was in the slow and muddled response to the breakout of the smoke. This led to scores of commuters being trapped on a smoke filled six- or eight-car train at L'Enfant Plaza for about 40 minutes before they were freed.

The train on which the commuters rode was also trapped. The conductor couldn't move the train forward out of the smoke-filled station, for reasons that aren't clear to me.  And he couldn't back the train out the station because the track was blocked from behind by other trains, which had been halted because of the smoke.
(There was an unconfirmed report a day or so after the incident that the conductor abandoned his train, which if confirmed would throw light on why the train didn't pull out of the station away from the worst of the smoke.)
    
The WTOP report didn't detail every one of the 10 issues but did mention one shocker: In response to the investigation thus far, Metro has made it procedure for a subway conductor to immediately shut off the air intake to a train in the event of a smoke incident.
   
Why in God's name the procedure was never before instituted by Metro is a mystery; it should be the first thing a conductor should do in those circumstances.  Because it wasn't done that day, poisonous thick smoke in the tunnel kept being sucked into the train cars on the trapped train. And as is now known, with no way for passengers on the train to open the emergency doors -- and with a delay of about 40 minutes before responders could get the doors opened.

By the way this wasn't simply smoke; it contained particles that once lodged in lungs can cause health problems for months and even years after the incident.

There were also complications with communications between various responding agencies, which created confusion.  One confusion was whether electricity to the third rail had been shut off in response to the smoke alarm. Reportedly the question delayed decisions about when to send firemen into the smoky tunnel to free passengers from the trapped train.  According to one early news report, without certain knowledge that power to the third rail had been shut off, those in charge decided it would be very dangerous to send firemen and other first responders into the smoke-filled subway tunnels.

If the report is confirmed I don't understand why the responders couldn't have simply walked on the side of the tunnels where the third rail isn't -- the rail is only on one side of the train cars.  Unless the tunnels intersect at angles and because of poor visibility due to the smoke the responders might have easily gotten confused about the location of the third rail.  In that event it's possible the delay in getting to the train was also due to authorities waiting for the thickest of the smoke to be dissipated by giant fans in the tunnels, which had been immediately turned on to clear the smoke.

As the mention of "ten" issues indicates, there are questions surrounding the incident in addition ones I've touched on.  And because there are so many agencies involved including the federal NTSB (National Transportation Safety Board), which investigates accidents on U.S. mass transport systems, the final report on the incident will probably be almost as many pages as the 911 Commission Report.

Yet when all the investigations are wrapped up and written up and all the finger-pointing in every direction is finished, the incident will amount to just one of those times when everything that could wrong did.

However, Metro (which also operates Washington, DC buses) has been plagued by safety issues on the subway system since at least as early as 2009.  Metro's long-running answer to complaints about the safety issues: We need more money and we need to have dedicated funds rather than sharing them with other agencies.

Of course mass casualty incidents that represent a confluence of missteps, mismanagement, and mishaps occur in every major city in the world.  I mention this one to a Pundita readership that is both national and international because the life-or-death gap between clear instructions and reality in the fire incident is worthy of everyone's note.

The emergency door exit system and instructions for using it were obviously given careful thought and surely garnered from best practices in subway systems in other cities. In light of this, there's no way subway passengers would be expected to remove two screws before they could exit through emergency doors. So the most likely explanation is that the screws were there to protect a panel on a train car during the crating, shipping, and uncrating processes, and that the screws were to be removed after the train cars were installed at their destination.

The same explanation is likely for the missing outside-door latches; it's a good guess they were to intended to be attached after the train cars had been uncrated and installed in order to protect them from damage during crating and shipping of the subway cars and/or while the car parts were being fitted together at their destination. 
 
In short it's unlikely this was a quality control problem arising at the factory; more likely this was an installation problem.  In any case the problem could have been caught at two levels:  inspection and drill.  If an inspection had failed, a drill in escaping from the cars would have caught that the emergency doors didn't work as expected.

So while there were a number of factors that caused a muddled response to a smoke incident, there was actually only one factor in play that nearly killed 85 people:  nowhere was it posted in the train when the last safety drill had occurred.

This is a world in which chances for human catastrophes multiply with the need to coordinate multiple agencies responsible for a mass system, a world in which the systems are increasingly complex.  In that mileu it's misplaced to put one's trust only in instructions; trust must also be placed in drills that routinely test the instructions.

Make no mistake, it was a close call. People who were freed from the train and able to talk spilled out a nightmarish story to reporters of passengers around them fainting, vomiting, and retching as the smoke overcame them.  The terrible irony is that just as the tunnels were being cleared of the worst of the smoke by giant fans, smoke was being pulled into the train cars, and with no way for the passengers to free themselves.  They had only moments left to live by the time they were rescued, and one wasn't able to hold out.
  
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