Safety board determines cause of deadly DC Metro accident

Long neglected safety hazards and a botched emergency response effort contributed to a D.C. Metro incident last year that left one passenger dead from smoke inhalation and dozens others sickened, a federal safety board said Tuesday.

{mosads}The National Transportation Safety Board (NTSB) offered the conclusions in approving its long-awaited findings on the cause of the January 2015 accident in which smoke filled a stalled train car, killing 61-year-old Carol Glover and sickening 91 other riders.

“The probable cause … was a prolonged short circuit that consumed power system components resulting from the Washington Metropolitan Area Transit Authority’s ineffective inspection and maintenance practices,” the report found.

“The ineffective inspection and maintenance practices persisted as the result of the failure of WMATA senior management to proactively assess and mitigate foreseeable safety risks and the inadequate safety oversight by the Tri-State Oversight Committee and the Federal Transit Administration.”

The safety board also adopted 33 recommendations for six different agencies.

This is the 13th NTSB investigation of the Washington Metropolitan Area Transit Authority, but NTSB Chairman Christopher Hart said Tuesday “little or no” progress has been made toward establishing a safety culture.

“WMATA, historically speaking, has had a severe learning disability,” NTSB Board Member Robert Sumwalt said. “Quite simply, they have not been willing to learn from prior events. … Learning disabilities are tragic in children, but they are fatal in organizations. And literally that is true in this case.”

The safety board found that problems with Metro’s electrical system, aided by water intrusion and improperly constructed protective cable sleeves, caused thick smoke to fill a train tunnel the afternoon of Jan. 12, 2015.

The transit agency ended its water inspection program in 2012, and the NTSB said Metro was aware of water issues as close to the accident as October 2014.

Rail traffic controllers failed to detect a smoke alarm during the January incident and did not stop all trains at the first reports of smoke and fire, which the NTSB said would have prevented the Yellow Line train car where Glover died from getting stuck in the tunnel near the L’Enfant Plaza stop.

Metro personnel deployed ventilation tunnel fans, but they were in “pull” mode, meaning smoke was drawn in the wrong direction, according to the safety board.

The NTSB said there were neither written procedures nor proper training on the ventilation system.

Officials also pointed out Metro has long been aware that its ventilation system needed upgrades, but did not act on the results of its own engineering study.

Rail controllers during the L’Enfant Plaza episode waited 15 minutes to notify D.C. emergency responders that a train was stuck inside the smoky tunnel. The train operator tried for 25 minutes to reverse the train to the platform, but the power failed as time went on.

Passengers evacuating the train were further put in danger by the lack of emergency lighting in the tunnel, the NTSB said.

“Whatever could go wrong that afternoon, did go wrong,” Sumwalt said.

Safety Recommendations

Among the slew of recommendations made Tuesday include fixing cable connector assemblies that were missing sleeves, which can cause electrical problems and fires.

NTSB had already made the urgent recommendation in June 2015, but Metro general manager Paul J. Wiedefeld testified at a congressional hearing last month that only 65 percent of the connector sleeves had been installed at that point.

The safety board also urged the Department of Transportation to transfer safety oversight of Metro to the Federal Railroad Administration. The department had instead opted to transfer temporary oversight to the Federal Transit Administration in the fall.

But Transportation Secretary Anthony Foxx, in a letter to Hart on Tuesday, pointed out that Congress would need to designate Metro as a commuter rail authority in order for the Federal Railroad Administration to assert oversight.

“It is entirely possible that we would still be awaiting such congressional action,” Foxx said.