The stinging words "anemic safety culture" rang loud and clear at the National Transportation Safety Board's report on the investigation of last summer's crash on the D.C. Metro system that killed nine people.
In presenting its final report on the crash, the board made a sweeping indictment of the Washington Metropolitan Area Transit Authority (WMATA), which carries about 750,000 passengers daily in Maryland, Virginia and the District of Columbia.
In her opening statement, board Chairman Deborah Hersman said listeners "are going to hear a lot about WMATA's anemic safety culture today," adding that a lack of preventive measures meant "the only question was when would Metro have another accident — and of what magnitude."
Metro's worst nightmare happened June 22, 2009, when Red Line train 212 struck Red Line train 214 near the Fort Totten station in the city's Northeast quadrant, causing the rear car of train 214 to telescope about 63 feet into the lead car of train 212, killing eight passengers and the operator of the speeding train.
The incident shocked the city and raised serious questions about the system's safety protocols. The report concluded, as expected, that faulty signal models caused the track to tell the operator of train 212 that the track was vacant when it wasn't.
But the NTSB ranged far and wide Tuesday in its criticisms during the hearing and in its report. It cited, among other reasons, thousands of alarm signals regularly ignored by employees and a lack of clear oversight of the Metrorail system because of the overlapping jurisdictions it serves.
Board members also spent a chunk of the day addressing their concerns that employees might be punished for reporting safety problems, a clear mark of the "ineffective safety culture," as the report called it.
NTSB board member Earl Weener, along with other panelists, agreed with Ms. Hersman's frustration.
"It seems that when it comes to safety recommendations, the organization was a bit like a sieve," he said.
Board members accused managers of taking a "reactive" rather than "proactive" approach on safety concerns. Even then, reactiveness didn't always take place, members asserted. As of February, WMATA had 49 corrective-action plans pending.
"There was an expectation and overreliance on the safety of the system, and they weren't progressive. They were complacent," Ms. Hersman said, calling the transit agency "tone-deaf" and stating bluntly that WMATA would have to pay heed to its recommendations.
"I think that our frustration is that if they don't listen this time, I'm not really sure what else can be done at this point," she said.
In the past 30 years, the agency has had 13 onboard, crash-related fatalities, nine of which happened in last year's Red Line crash. But, as the NTSB highlighted, Metro has had a series of serious safety breaches even after that crash.
Three workers were hurt in November when a train hit a stationary train at a Metro park. In December, a team of inspectors was nearly hit by a train that Metro officials say was traveling too fast. In January, two veteran workers were struck and killed by a maintenance truck on a track closed to regular service.
NTSB board members cited a 2005 incident at the Rosslyn station on the Orange Line as a case study of WMATA's seeming inability to learn from its mistakes.
In that incident, the system indicated that the track ahead was clear, but the operator could see it was not. The operator braked just feet from the train in front of her.
If the changes that oversight agencies recommended after that incident had been implemented throughout the Metro system, members of the board said, the fatal 2009 crash could have been prevented.
The Metro system was sending out a different message Tuesday — one of eagerness to accept NTSB's recommendations. Its home page flashed a screen shot Tuesday afternoon of one of its trains with the words "Metro adheres to NTSB suggestions" and "Moving forward on safety" across it.
"Today at Metro there is no higher value or priority than safety," Richard Sarles, Metro interim general manager, said in a press release on Metro's site. "We have taken dozens of actions just in the last year, to improve safety for our customers and employees. And I pledged that we will carefully consider the comments, findings and recommendations that come forth from the National Transportation Safety Board today, and continue to work cooperatively with the NTSB, just as we have in advance of today's meeting."
No Metro representative was available to speak with The Washington Times on Tuesday.
Members severely criticized Metro for putting a higher priority on moving trains than on safety, something they found pressured even the team and managers responsible for ensuring safety to ignore their responsibilities.
"Safety culture starts at the top and permeates throughout," said Robert Sumwalt, an NTSB member who criticized Metro officials for saying safety starts at the bottom of the organizational flow chart, not the top.
NTSB members also cited a fundamental flaw in the agency's structure, saying that oversight agencies such as the Federal Transit Authority and the Tri-State Oversight Committee — consisting of officials from Maryland, Virginia and the District of Columbia — had no power to enforce safety regulations on WMATA.
The NTSB called on Congress to enact legislation creating clear lines of authority and oversight that would expedite safety-related changes — a call that the oversight committee's top official quickly endorsed.
"The observations that the NTSB made about the challenges [the oversight committee] faces with regard to regulatory authority are spot-on," committee Chairman Matt Bassett told The Times.
Sen. Barbara A. Mikulski, Maryland Democrat, called the report "both chilling and very sad" and told reporters that WMATA should implement NTSB recommendations and that Congress should order new safety standards from the federal Transportation Department and let that agency enforce them.
Board members also harped on WMATA's board of directors for failing to give oversight on safety, which is not only within their ability, but is their responsibility, according to the members' findings.
Unlike other transit agencies, WMATA doesn't have the word "safety" in its mission statement, not even in the one adopted by the board just months after the June 2009 crash. Rather, WMATA's statement reads, "Metro provides the nation's best transit service to our customers and improves the quality of life in the Washington metropolitan area."
"I'm afraid if any board of directors is waiting for information to be brought to them, they may never get the information that they need," said Steve Klejst, one of the NTSB investigators assigned to the accident.
Mark Littman, a spokesman for the Los Angeles County Metropolitan Transportation Authority, said safety has to be the No. 1 priority in any operation like the Metro system.
"Safety is our first credo," he said. "When you operate in an urban environment like we do, you have to be vigilant."
Although the Los Angeles system boards 163,000 people per day on its subway systems, less than a quarter of the WMATA's burden, Mr. Littman said, safety training and communication permeate his system efficiently.
No crashes have occurred in the past two decades of the subway system operations, Mr. Littman said, adding that a crash would be impossible because the systems there detect train presence and respond automatically.
"We have positive train control on the subway so you can't have two trains on one block," he said. "They would stop automatically."
The lack of consistency in safety staff leadership was criticized at the meeting, too. Since 1996, the chief safety officer had the reporting structure changed eight times, and the safety team had a staff vacancy rate averaging about 25 percent.
"They do need stability and continuity," said Ms. Hersman, who also questioned the turnover within WMATA.
Ms. Hersman especially criticized the approximately 8,000 alarms that go off per week, routinely ignored by Metro employees. The NTSB determined that the alarms were ignored because they were inaccurate so often.
"It's definitely a surprise to see how inept some of these things are," Ms. Hersman said.
Developing non-punitive reporting systems, holding employees accountable, establishing sound policies and procedures and engaging the board of directors and general managers and learning from bad things are all steps members said WMATA can take toward becoming a culture of safety.
Board members said the process of cultivating a culture of safety will take months and years.
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