The NTSB cites a signal circuit failure in the deadly June 2009 crash, as well as a broader failure in Metro’s safety management system.
"Metro was on a collision course long before this accident."
Those were the chilling words by NTSB Chairman Deborah Hersman, who said Tuesday that Metro has embraced a culture that does not put the safety of its passengers first. She said that contributed to last year's train crash -- the deadliest in the transit agency's history.
The train crash that killed nine people and injured dozens of others in June 2009 was caused by a technical problem that was compounded by the transit system's lack of a safety culture, according to investigators speaking at NTSB's meeting.
"When safety is more important than schedules, their organizational culture can be a success," Hersman said.
A recreation of the deadly crash shown during the hearing showed what went wrong on June 22, 2009. According to NTSB, when Red Line Train 112 struck Train 214, Metro's train detection system failed in two ways. First, it showed that Train 214 was not stopped and on the tracks when it actually was. Second, the automatic system had Train 112 move forward at full speed. By the time the operator saw the stopped train, investigators said she used the brake, but it was only enough to slow the train.
"In a larger sense, the safety board's investigation revealed much more than the failure of a track circuit," Hersman said. "The layers of safety deficiencies uncovered during the course of this investigation are troubling and reveal systemic breakdown of safety management at all levels."
Family members of the train operator who was killed that day watched as NTSB officials explained that, over the years, Metro's management has chosen not to implement NTSB safety recommendations, including the replacement or retrofitting of the 1000 series trains. That recommendation was made after a 2004 crash at Woodley Park that showed that the cars could not withstand strong impact.
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"Because the necessary preventative measures were not taken, the only question was when Metro would have another accident and of what magnitude," Hersman said.
NTSB said that Metro's train detection system was operating so poorly that they couldn't even run tests to see what was wrong with it. NTSB said that the tests couldn't even run without malfunctions, causing them not to be able to do the safety checks.
And yes, this is on the very same system that Metro riders use every day.
Shortly after the NTSB meeting began, Metro sent out a press release to the media as a reminder about all of the safety changes that have been made since the 2009 crash, including the fact that they are now operating trains in manual mode.
"We have begun to see the beginning of a safety culture shift from one that was reactive to one that is proactive in taking steps to solve and correct issues, so that issues don’t become problems,” Metro's interim GM Richard Sarles said, citing the agency’s decision to pull all 100 of the 4000 series railcars to fix the door motors as an example of a precautionary proactive action.
Metro said it also has sandwiched the 1000 series cars in between newer cars on trains. NTSB officials, however, said that is no replacement for safety and that doing that is not a part of their recommendation.
Metro also said in its release that, as of Monday night, it had contracted out the building of new 7000 series trains to replace the 1000 series.
