The June breakdown of a Baltimore-bound commuter train — which left up to 1,200 people sweltering for about two hours and became known as the "hell train" — was worsened by the managerial lapses of MARC and Amtrak, according to a report released Thursday.
Once Penn Line Train 538 stopped near New Carrollton station, communications broke down, the Amtrak crew lost sight of passengers' needs and MARC managers were slow to respond. The report, based on an investigation coordinated by the Federal Railroad Administration, concluded that the June 21 incident reflected "a series of organizational failures at multiple levels."
The breakdown occurred on an evening when the mercury hovered around 90 degrees, and passengers said temperatures on the sealed train became even hotter, until they began evacuating in spite of the crew's orders. With MARC and Amtrak slow to call in emergency workers, passengers summoned help with calls to 911.
The report also exposed a longstanding problem with maintaining power to long, heavy trains in hot weather — prompting MARC and Amtrak to consider running shorter trains at more frequent intervals. Such a move could involve a restructuring of Amtrak's schedule in the Northeast Corridor and additional spending by the Maryland Transit Administration.
In a memo to Maryland Transportation Secretary Beverly Swaim-Staley, MTA Administrator Ralign T. Wells identified "critical factors" in the incident, which led to the hospitalization of several passengers and unflattering national publicity about MARC and Amtrak. The stranding of what Gov. Martin O'Malley called the "hell train" became an issue in this year's gubernatorial election and a focal point for dissatisfaction with unreliable MARC service and spotty communication with passengers.
Swaim-Staley and Wells met with members of the MARC Riders Advisory Council in Washington Thursday afternoon to discuss the report.
Rafi Guroian, chairman of the council, said afterward that the report was "very realistic about what went on that day." He said he was disappointed, however, that it concentrated on how to respond to the next incident rather than on how to prevent a repeat.
After the incident, Penn Line operator Amtrak took much of the responsibility for the failure to respond promptly to the misery of passengers. But the report was highly critical of MARC officials, too.
"MARC management left the task of resolving the incident in the hands of the contractor, Amtrak, rather than becoming a more active participant," the report said. "MARC management failed to dispatch staff to the scene in order to evaluate the situation, communicate directly with MARC management and assist in coordinating an appropriate response."
In an interview Thursday, Swaim-Staley said she holds MARC and its staff equally responsible for the failures that day. She pledged that in the future the MTA would call on agencies such as the State Highway Administration to help deal with emergencies.
"If your providers are not being responsive, it's up to MARC and the MTA to reach out to the department, to the SHA, to anyone they need to get the resources they need to deliver," she said.
The report says that MARC employees were disciplined in the aftermath of the incident, but Swaim-Staley — citing state personnel law — declined to comment on the number of workers affected and the severity of the punishment.
One rider who suffered through the roasting aboard Train 538, congressional staffer Jaime Lennon, said she found the report to be "very thorough."
"Obviously they took the incident as seriously as was warranted and made some pretty good recommendations," she said.
Lennon, a communications aide to Rep. C.A. Dutch Ruppersberger, D-Md., was particularly glad to see the recommendation that MARC equip crews with bullhorns to use when the public address system fails — as it did aboard Train 538. "The biggest issue that day was the lack of communications to the passengers," she said.
In fact, many of the report's recommendations focus on improving MARC's communications with passengers, Amtrak and CSX, operator of the Camden and Brunswick lines. Among other things it recommended cross-training of employees of MARC and the two railroads in emergency response and communications procedures.
Swaim-Staley and Wells said the MTA had learned many lessons from the incident and began applying them as early as last summer, when the system was tested by numerous 90-degree days and severe storms.
In his memo, Wells said the critical factor in bringing the train to a stop was the failure of two electronic components on the MARC-owned HHP-8 electric locomotive. The investigation did not determine the cause of the failure but said heat in the engine compartment and a power fluctuation in Amtrak's overhead power system were likely factors, he said.
Once Train 538 ground to a halt about seven minutes after leaving Union Station, Wells said, the problem was compounded by the failure of Amtrak to provide MARC management with "accurate and timely" information about the breakdown. In addition, he said, the Amtrak crew focused their efforts on the mechanical problem and failed to pay attention to the well-being of the passengers or to communicate with them.
Amtrak released a statement in response noting that the report also detailed corrective actions it and the MTA had taken. "We take this matter very seriously and take responsibility for our actions that contributed to the unacceptable situation," the railroad said, adding that since the incident it has retrained its crews.
The report also criticized MARC managers for failing to recognize the seriousness of the incident and to respond aggressively. Wells said neither MARC nor Amtrak acted quickly enough to call in first responders, leaving it to MARC passengers to summon help with their calls to 911.
In a section prepared by the consultant Booz Allen Hamilton for the MTA, an assessment team of transit professionals identified eight "best practices" developed by the American Public Transit Association for emergency response and evacuation plans. It said only one of those practices was being followed by MARC at the time of the incident.
"What should have been a routine maintenance‐related procedure or train recovery operation escalated into an emergency situation and exposed fractured processes for passenger communications, emergency management and train evacuation," the assessment team concluded.
The report identifies a compounding series of lapses, including a basic miscommunication over the location of the broken-down train. The report said Amtrak's commuter desk at Union Station reported that the train was inaccessible, when in fact it was stalled right next to U.S. 50.
MARC trains are not equipped with GPS technology, but Swaim-Staley characterized the communications lapse as a human error and said the preferred solution is to have a MARC representative in Amtrak's control center.
According to the investigation, Amtrak and MARC failed to seek help from local police and emergency services as temperatures rose inside the cars. The report says an Amtrak police officer arrived at the scene 35 minutes after the train stalled and helped passengers open emergency doors and windows, but it faults his department for failing to provide additional support as conditions on the train deteriorated.
It was not until passengers called 911 that Prince George's County emergency services responded, the report said.
The report proposes fixes to each of the problems, including a move toward shorter and lighter trains that would put less strain on locomotives during hot weather. It said that to make up for the lost capacity on each train, Amtrak and MARC are developing a plan to add four trains each day — two each in the morning and evening peak travel times.
According to the MTA, it would have to hold public hearings before taking such a step. Wells said MARC also has adopted the practice of using two diesel locomotives on trains that do carry a heavier load rather than a single electric one.
Guroian, the advisory council chairman, said it was "very troubling" that the report didn't pin down the cause of the engine failure, and he criticized the idea of using double diesel engines on the Penn Line in place of electric locomotives.
"I would call it a Band-Aid fix," he said, adding that the diesel engines go 20 mph slower than their electric counterparts.
Still, Guroian said he has seen many catastrophic MARC breakdowns but never as serious a high-level response. He said, "It's the media coverage in an election year that prompted the MTA to react the way they did."
Timetable
Sequence of events on MARC Train 538 on June 21. All times p.m.
6:13 Train 538 departs Washington's Union Station.
6:20 Engineer tells Amtrak traffic control 538 is stopped.
7:17 Amtrak rescue engine gets close to the train and waits for conductor of Train 538.
7:40 Train 538 engineer tells rescue engine parking brake
cannot be released.
8:15 538 engine up and running. Passengers off train and
emergency responders on the scene. Train 442 arrives to transfer passengers, leaving 100 still aboard.
9:18 Train 538 moves north to New Carrollton Station to transfer remaining
passengers onto Train 544.
SOURCE: Booz Allen Hamilton