NTSB Reveals Probable Cause of Fatal Metro Accident, Alarming Operational Errors

— -- Safety officials today slammed a series of “disturbing” blunders within the Washington, D.C., metro system, which they say contributed to the L’Enfant Plaza track fire that killed one passenger and injured 91 other people in January 2015.

Following an electrical arcing incident on the yellow line’s high-voltage third rail, hundreds of riders were trapped underground in a dark, smoky train for nearly an hour, unable to pry open the doors. As a voice on the loudspeaker urged passengers to “remain calm,” survivors say, many were coughing, choking and crying. A 61-year-old mother died of respiratory failure, and scores more suffered from smoke inhalation.

Numerous issues -- including a malfunctioning smoke detector, an ineffectively deployed ventilation system, and poor communication with first responders, who spent several minutes fumbling around the wrong tunnel -- intensified the situation, officials from the National Transportation Safety Board explained today.

“Safety is still not institutionalized as a core value at WMATA,” said NTSB Chairman Christopher Hart, adding that oversight of the Washington Metro Area Transit Authority “has proven uniquely dysfunctional.”

Hart's comments reinforces the need for a culture change, WMATA General Manager Paul Wiedefeld, who took over after the L'Enfant Plaza incident, told reporters today. "We have to get the infrastructure correct, we have to get the policies right, we have to get the people right, and that's what I've been trying to do since day one, and I'll continue to do it," Wiedefeld said.

According to the NTSB, WMATA lacked comprehensive written procedures for responding to smoke and fire events in tunnels -- and didn't follow standard operating procedures where they had them.

For example, WMATA procedures dictate the control center stop all trains in both directions when smoke is reported in a tunnel. But disturbingly, according to the NTSB, rather than halting trains, "it was common practice to use trains with passengers to investigate reports of fire or smoke instead." However, according to Wiedefeld, using revenue trains to investigate smoke "does not occur."

"If WMATA had followed this standard operating procedure and stopped all trains at the first report of smoke, train 302 would not have been trapped in the smoke-filled tunnel," NTSB officials said today.

Prior to the L’Enfant incident, the transit agency also failed to install sealing sleeves to protect cables from contaminants and moisture, the NTSB said.

This isn't the first time the NTSB has noted deficiencies in metro's safety culture. In fact, the L’Enfant investigation is the ninth accident since 2004.

Following a deadly collision near the Fort Totten in 2009, NTSB investigators chastised WMATA for its disregard for safety.

“Many of the same organizational and oversight shortcomings that we cited in 2009 continue to plague WMATA,” Hart said today. “Little or no progress has been made toward building a meaningful safety culture.”

The NTSB's criticism didn't stop with the Metro. Officials also noted that the DC Fire Department and EMS had not practiced a full-scale tunnel evacuation for five years, and was unprepared to respond the fatal accident at L'Enfant Plaza.