NTSB: Ineffective inspection, maintenance led to WMATA's fatal smoke incident

The National Transportation Safety Board (NTSB) announced yesterday that ineffective inspection and maintenance practices led to a short circuit that caused a fatal smoke incident on a Washington Metropolitan Area Transit Authority (WMATA) train early last year.

In a scathing report and in statements made at a hearing on the incident yesterday, the board said the Jan. 12, 2015, incident that killed one person and injured 90 others 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 (FTA).

"From WMATA's lack of certain safety procedures and its deviation from established ones, this accident reveals a compromised safety system and dysfunctional organizational culture," NTSB Chairman Christopher Hart said in a prepared statement.

Yesterday's hearing marked the close of NTSB's 13th investigation into WMATA accidents — eight of which involved fatalities. The board's 200-page report includes investigators' findings that call into question WMATA's ability to use information gained since those previous incidents.

"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 incident resulted from WMATA's failure to follow its own procedures for washing tunnels and constructing power cable connector assemblies. Had WMATA followed its standard operating procedures that called for stopping all trains at the first report of smoke, the accident train would not have been trapped in the smoke-filled tunnel, according to the report.

The incident occurred near the train shortly after it left the L'Enfant Plaza Station in Washington, D.C. The train and tunnel filled with smoke.

NTSB investigators also found 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 problems throughout WMATA, including infrastructure maintenance, tunnel ventilation, rail-car ventilation, responses to reports of smoke and management deficiencies.

Furthermore, the board said the District of Columbia Fire and Emergency  Medical Services Department was unprepared to respond to a mass casualty event on WMATA's underground system.

The board also said that the FTA does not wield the same regulatory authority to compel railroad safety as the Federal Railroad Administration (FRA).

"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."

The board issued 31 new safety recommendations — 23 to WMATA. Also receiving safety recommendations were the FTA, the D.C. mayor, the D.C. Office of D.C. Office of Unified Communications, the D.C. Fire and Emergency Medical Services Department and the National Capital Region Emergency Preparedness Council.

Besides the report, the NTSB released this video describing the incident and showing the tunnel evacuation. An abstract of the report can be read here.