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Passengers would not have become trapped in a smoke-filled tunnel near the L’Enfant Plaza station last January if Metro had followed “its standard operating procedures,” according to the National Transportation Safety Board.

That was just one of 43 findings NTSB outlined at an hours-long hearing on Tuesday in which the federal body delivered its final report on the incident, which left one woman dead and sickened dozens of others. Among the board’s findings:

  • Railcars filled with smoke in part because of a rule that requires train operators to get permission from Metro’s control center to shut off train ventilation systems;
  • First responders were delayed by inefficient communications between the control center and D.C. Fire and Emergency Medical Services;
  • Metro had “put passengers at risk by routinely using trains [in revenue operations] to investigate reports of smoke or fire” in tunnels. The board’s Vice Chair T. Bella Dinh-Zarr called this practice “reprehensible.” Metro General Manager Paul Wiedefeld told reporters that trains are now “offloaded” if they’re used to do so.

“Something is fundamentally wrong,” NTSB Chair Christopher Hart said in introductory remarks that touched on investigations into Metro over the past four decades. “Here, that is safety oversight.”

NTSB also established a “probable cause” for the incident, which it characterized as a “prolonged short circuit that consumed power and system components resulting from [Metro’s] ineffective inspection and maintenance practices.” NTSB investigators highlighted two particularly acute issues related to the emergencies throughout the rail system: water intrusion into tunnels that corrodes power infrastructure, creating a risk of arcing insulators, and the lack of a system to find smoke in tunnels (Metro has detectors in stations, fan shafts, and power substations).

The NTSB also identified a lack of properly constructed power cable connector assemblies, insufficient training for control-center staff on how to operate tunnel ventilation fans, and below-standard lighting levels and signs in tunnels that could have crucially assisted emergency responders.

“The ineffective practices persisted as a result of the failure of [Metro] 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 finding of probable cause reads. “Contributing to the accident were [Metro’s] failure to follow established procedures and the District of Columbia Fire and Emergency Medical Services Department’s being unprepared to respond to a mass casualty event on the [Metro] underground system.”

Dozens of those injured in last January’s incident have sued Metro, and today’s findings are likely to help their cause.

NTSB member Robert Sumwalt described Metro as having a “severe learning disability” in terms of fixing previously identified problems. But he referred to Wiedefeld, who came to Metro late in 2015, as the “new sheriff in town.”

In addition, the NTSB’s report criticized the Office of Unified Communications for lacking specific Metro emergency-response training, pointing out that it took the agency four minutes and 19 seconds to process the control center’s call for service on Jan. 12. Likewise, the board said, some of FEMS’ radios worked so poorly during the incident that first-responders had to rely on “runners” to relay information.

NTSB also expressed concern that the FTA does not have the right expertise to oversee Metro safety this year, even temporarily. Dinh-Zarr extolled the Federal Railroad Administration as an alternative, noting that the agency has greater authority to levy fines on Metro for noncompliance. The FTA has repeatedly argued that it can handle the job, including at a recent congressional hearing about Metro. Following today’s NTSB session, the FTA released a letter U.S. Department of Transportation Secretary Anthony Foxx had sent to the board, reiterating that claim.

Ultimately, the NTSB issued more than 30 recommendations, mostly to Metro, as part of its report. City Desk will update this post with them as soon as they’ve been finalized and become public.

Update 5:30 p.m.: The NTSB’s new recommendations to agencies include the following (you can read them all here):

Metro

  • “Review and revise your tunnel inspection, maintenance, and repair procedures to mitigate water intrusion into tunnels.
  • Develop location-specific emergency ventilation configurations based on engineering studies of the [Metro] tunnel ventilation system.
  • Install and maintain a system that will detect the presence and location of fire and smoke throughout the Washington Metropolitan Area Transit Authority tunnel and station network.
  • Ensure that all train operators are trained and regularly tested on the appropriate procedure for emergency shutdown of railcar ventilation.
  • Develop and incorporate a comprehensive program for training Rail Operations Control Center control operators in emergency response procedures including regular refresher training.
  • Implement a regular schedule for the inspection and removal of obstructions from safety walkways and track-bed floors to ensure safe passageways for passengers to use during a tunnel evacuation.
  • Revise your standard operating procedures to require that an after-action review be conducted of all emergency responses to events with passenger or employee fatalities, and publish the results, including both the successes and the potential deficiencies of your responses, to help ensure that deficiencies are appropriately remediated.”

FTA

  • “Issue regulatory standards for tunnel infrastructure inspection, maintenance, and repair, incorporating applicable industry consensus standards into those standards.

D.C. Mayor’s Office

  • “Convene an independent panel of experts to assess the District of Columbia Fire and Emergency Medical Services Department’s preparedness to respond to mass casualty events in the [Metro] underground system, identify and make recommendations to improve this preparedness, and share the findings of that assessment with the other local jurisdictions with [Metro] underground systems.”

FEMS

  • “Implement measures to train all command officers who will serve in the role of incident commander in the skills and practices of National Incident Management System incident command and unified command processes. This training should include regular refresher training.”

OUC

  • “Audit your public service answering point (PSAP) to validate compliance with the standards published by the National Emergency Number Association or another similar standards organization. The audit should determine the average length of time that call takers use to process an emergency call and dispatch emergency service and compare those results with those of other comparable PSAPs.”

Screenshots of L’Enfant Plaza smoke incident via NTSB