A short circuit on Washington’s Metrorail system that caused thick smoke to fill a stranded train, killing one passenger and injuring 91 people on Jan. 12, 2015, was the result of WMATA failing to follow its own safety procedures and inadequate safety oversight by the Tri-State Oversight Committee and the Federal Transit Administration, according to a report by the National Transportation Safety Board.

“From WMATA’s lack of certain safety procedures and its deviation from established ones, this accident reveals a compromised safety system and a dysfunctional organizational culture,” said NTSB Chairman Christopher A. Hart.

Didn't learn their lesson

In a nearly 200-page report, investigators presented findings that called into question WMATA’s ability to apply the information gained since 1982 through 12 accidents previously investigated by the NTSB, eight of which involved fatalities. “The NTSB concludes that WMATA has failed to learn safety lessons from NTSB studies and accident investigation reports,” the report stated.

The short circuit in the January 2015 accident resulted from WMATA’s failure to follow its procedures for washing tunnels and constructing power cable connector assemblies. NTSB investigators said if WMATA had followed its standard operating procedures, stopping all trains at the first report of smoke, the accident train would not have been trapped in the smoke-filled tunnel.

A "chaotic state"

The NTSB investigation also showed that the WMATA control center was in a chaotic state as the emergency unfolded. “The right hand didn’t know what the left hand was doing,” one control operator told investigators.

The report cited safety vulnerabilities throughout the WMATA system, including infrastructure maintenance, tunnel ventilation, railcar ventilation, responses to reports of smoke, and management deficiencies. The investigation also found that the Federal Transit Administration’s ability to compel safety compliance is not equal to that of the Federal Railroad Administration because the Federal Transit Administration’s safety authority does not wield the same regulatory enforcement tools as the Federal Railroad Administration.

“Transforming a culture where deviations from the very procedures designed to keep people safe is the norm, to a culture that is intolerant of compromises in safety is a significant challenge for WMATA,” said Hart. “But that kind of change can be done and it must be done for the sake of all, including me, who ride on this metro system.”

Recommendations issued in accident's wake

The NTSB issued 31 new safety recommendations in the report. In addition, nine safety recommendations were previously issued. The Washington Metropolitan Area Transit Authority received 23 of the new recommendations. Also receiving safety recommendations were the Federal Transit Administration, the mayor of the District of Columbia, the D.C. Office of Unified Communications, the D.C. Fire and Emergency Medical Services Department, and the National Capital Region Emergency Preparedness Council.

The accident synopsis, findings, probable cause and safety recommendations are available at: www.ntsb.gov/news/events/Documents/Abstract_DCA15FR004.pdf