MTA IG: Worker errors to blame for LIRR outageBy
An unexpected lightning strike that took out Long Island Rail Road service near Jamaica had some help from LIRR workers executing a flawed process, a report released today by the MTA Inspector General said. On September 29, 2011, a lightning strike knocked out the LIRR signal system, delaying service across the region. A few hours later, an LIRR worker disabled another signal system while attempting to repair the damaged one, and all service shut down. The report, available here as a PDF, is not a particularly glowing one for the LIRR.
With a new signal system in place, the LIRR should have been prepared for such an outage. It was instead a 12-hour shutdown, and the IG had the following to say:
- LIRR personnel performed deficient Quality Assurance/Quality Control both during and after installation of the new system. Specifically, LIRR failed to detect both the installation of the wrong serial server connector as well as the non-installation of certain components shown on the original ASTS design.
- The diagnostic tools pre-programmed by ASTS into the new signaling system failed to pinpoint which critical components were not functioning. This complicated LIRR’s identification of the failure’s cause, thereby extending the duration of the incident.
- ASTS did not provide LIRR with operating manuals for the system as a whole, nor did ASTS provide LIRR with adequate troubleshooting procedures. Additional training of LIRR personnel by ASTS on troubleshooting could have mitigated the duration of theoutage and prevented the human error that brought down the signals at the second signal hut.
- LIRR employees did not have adequate replacement parts to diagnose and correct system problems. For its part, ASTS did not provide LIRR with a list of critical spare parts after its design was completed.
- The LIRR Signals Department was unaware of a separate contract modification with ASTS to provide emergency response services in situations just like the lightning strike. Further, ASTS failed to provide LIRR with the contract-required phone number and e-mail address to obtain immediate emergency assistance. LIRR did not attempt to contact ASTS using existing known contact information during the first five hours of the disruption.
The ultimate conclusion is an obvious one: “Believing that it had contracted for and installed a system providing appropriate redundancy and protection, LIRR was not adequately prepared for this emergency.”
By and large, the various recommendations in the report are fairly obvious. The Rail Road needs to work closely with its technology vendors to ensure adequate documentation and training. It must also train its workers in the maintenance of the technology to avoid future accidents. That we needed an incident and an IG report to reach that point is dismaying.
From a rider perspective, though, the Inspector General did not find the LIRR adequately informed its passengers of the outage, and that’s something easily fixable. The Rail Road, says the report, “should further develop and refine its protocols to facilitate the dissemination of appropriate information to passengers on stranded or standing trains regarding why they are stopped, and the plans being pursued and progress being made to get them going again.” Shouldn’t that be a lesson from Customer Service 101?